Recommendation		Page
1	The Board recommends that ESHT engage at an earlier stage with HOSC on any future service changes, particularly where there might be public interest in the service in question.	10
2	The Board recommends that ESHT involve staff and representative groups including Healthwatch and the East Sussex Parent Carer Forum in the design and fitting out of the new dedicated paediatric space where possible, to ensure it is child friendly, child safe and meets patients’ and their families’ needs.	14
3	The Board recommends that Healthwatch and Young Healthwatch be asked to visit and assess the new dedicated paediatric space and service once it has been completed.	14
4	The Board recommends ESHT investigate developing the space in the Scott Unit for facilities for planned paediatric care activities.	14
5	The Board is concerned that many of the pathways were not finalised before the new model was rolled out and recommends that ESHT finalise the outstanding planned care pathways as soon as possible and that copies of the new clinical pathways documentation are provided to HOSC once finalised and agreed with staff.	15
6	The Board recommends that additional communications are provided to parents and carers that are affected by the any of the changed pathways as a matter of urgency, so that families and their children who are regular users of the services at EDGH understand how the changes may affect them.	15
7	The Board remain concerned about having sufficient Paediatric consultant presence at the EDGH site and recommends that ESHT permanently locates the Paediatric consultant staffing the GP triage phone at the EDGH site to provide a level of consultant input into the new service model and to provide additional assurance to address concerns about the level of consultant presence in the new model.	17
8	The Board recommends that ESHT consider identifying a suitable space that could be used for children and young people presenting with mental health issues within the facilities in ED.	18
9	The Board recommends that ESHT reviews and expands the number of trainee APNP roles if possible, to provide greater resilience and assurance for the operation of new service model.	20
10	The Board recommends that ESHT promote the travel and access support that is available to patients and their families, who may be affected by changes in the new model of care, and consider the use of a Travel Liaison Officer role to support travel and access arrangements.	21
11	The Board recommends that ESHT clarifies the metrics and milestones used to determine the effectiveness of the changes to paediatric care at EDGH to HOSC and Healthwatch.	22
12	The Board recommends that ESHT provides an update report to HOSC on the operation of the new service model at the 6 June 2024 and 12 December 2024 HOSC meetings.	22
13	The Board recommends that HOSC works with Healthwatch to monitor and review the operation of the new service model.	22

Introduction

1. On 14 December 2023 the Health Overview and Scrutiny Committee (HOSC) considered a report from East Sussex Healthcare NHS Trust (ESHT) on changes to the Paediatric service model at the Eastbourne District General Hospital (EDGH). The Committee also received a number of written representations from members of the public and staff expressing concerns about the proposed changes, which it considered alongside the report. The Committee asked detailed questions about the proposals to try and ascertain the impact on:

· the sustainability of the services;

· patient safety;

· patient care and experience, including facilities for the treatment of children;

· travel and access; and

· the staffing of the new model of care.

2. Both NHS Sussex, who are the responsible body as service commissioners, and ESHT do not regard the changes as a substantial variation to services which would require formal consultation with HOSC. The changes are considered to be operational differences in the way in which the current services are provided. They do not consider the changes as representing a removal of existing Paediatric services from the EDGH site and do not consider the changes will result in more children having to attend the Conquest Hospital in Hastings.

3. The Committee agreed to establish a Review Board to examine the impact of the changes to the Paediatric service model at EDGH more closely and requested ESHT pause the implementation of the changes to give HOSC the time to examine the proposals in more detail. However, for operational reasons the Trust decided to continue with the implementation of changes to paediatric services which started on 8 January 2024 and will be carried out in two phases. The second phase will start once a new modular building is ready for use in early March 2024.

4. The Review took place over a series of meetings held during February 2024, which examined a range of evidence from ESHT staff, Healthwatch, East Sussex Parent Carer Forum (ESPCF) and members of the public. This included the submissions and concerns raised by members of the public and staff that HOSC had received regarding the service changes. These issues, together with the Committee’s own observations, informed the scope of the review which included:

· What has changed and the impact of the changes on patient safety, particularly for those children whose pathway is different from the previous service model;

· The impact on patient care and experience, including the new facilities for the treatment of children;

· Travel and access impacts of the service changes; and

· Staffing and sustainability of the services, including operational hours and Paediatric consultant cover and supervision.

5. The Review Board has considered evidence from a range of witnesses and sources including the ESPCF and has made a number of recommendations which it considers will help provide assurance about the impacts of the new model of care, and to make changes where the Board believes adjustments are needed. The Board has also recommended working with Healthwatch to monitor and review the new service model.

6. The report of the Review Board has been agreed by the majority of the Review Board members. However, after hearing all evidence and witnesses Cllr Shuttleworth has concerns about aspects of the new service model and is not in agreement with all the findings and recommendations of the report as set out in appendix 2.

Background

Current Services

7. Acute Paediatric service provision at ESHT is split across the two acute hospital sites, the Conquest Hospital in Hastings and EDGH. All in-patient care, emergency and higher acuity need is met at Conquest Hospital, along with outpatient services, planned investigations and inpatient surgical needs. EDGH does not have an in-patient ward but does provide urgent care, outpatients, planned investigations and day surgical services. Both sites deliver a specific range of planned and outpatient paediatric care.

Conquest Hospital

Eastbourne District General Hospital

· Inpatient Paediatric Ward

· Short Stay Paediatric Assessment Unit (SSPAU)

· Special Care Baby Unit

· Outpatients

· Short Stay Paediatric Assessment Unit (SSPAU)

· Outpatients

· Day Surgery

8. On both sites a Short Stay Paediatric Assessment Unit (SSPAU) was set up some years ago, to support urgent care activity. However, the majority of urgent care for children is actually provided by each Emergency Department (ED). Since being set up, the use of the SSPAU at Eastbourne for urgent care cases has been relatively low (3 to 4 per day) although the unit has also been used for some planned care, such as outpatient and blood test activity to utilise the capacity more effectively.

9. The EDGH provides urgent care for paediatric cases in the Emergency Department (ED) and Urgent Treatment Centre (UTC), and a small number of children were previously seen in the SSPAU which was located some distance away from the ED in the Scott Unit. The EDGH SSPAU was previously only open 5 days per week (weekdays), from 9am - 7pm, due to staffing challenges and was not open at weekends. This meant children were not being transferred to the assessment unit after 4pm for observation due to it being closed at 7pm.

New Service Model

10. Under the new service model which started on 8 January 2024, the planned and emergency/urgent care patients formerly seen in the SSPAU will be seen in different places within the Eastbourne hospital site. The majority of planned care formerly carried out by SSPAU, will be carried out as part of the Outpatients department at the EDGH (e.g. blood tests, endocrine tests, and food challenges).

11. The urgent and emergency care patients that were seen in the SSPAU will instead be treated in a dedicated paediatric area next to ED once a new modular building is in place. At present the existing space being used is shared with Emergency Nurse Practitioners (ENPs) who are treating children. The ENPs will move out when the new modular building is in place and ready for use. It is estimated that the new modular building will be ready around 8 March 2024. The dedicated paediatric area will be staffed by Advanced Paediatric Nurse Practitioners (APNP), who are paediatric specialists equivalent in paediatric training to Registrar doctors or a registrar, and by two Paediatric nurses. This is different to the previous model of care in the SSPAU which was a Paediatric consultant led service.

12. The service model changes move the specialist paediatric urgent and emergency care services to the “front door” of the hospital adjacent to the ED which is in line with best practice. ESHT has stated this will improve patient experience and the sustainability of these services and will ensure that children in Eastbourne with urgent care requirements have more timely access to paediatric expertise. The new service model operating hours are 8.30am – 9.00pm on weekdays and it has been operating some weekends. The intention is to provide the new service 7 days a week when there is a full complement of staff.

13. ESHT has made it clear that Outpatient clinics will be unchanged and minor surgical procedures (day case, elective surgery including the new elective hub when built) will continue to be provided at EDGH. ESHT has also confirmed that the number of paediatric consultants employed by the Trust will not change, as a result of the planned improvements.

Patient Numbers

14. The EDGH had 13,471 children attending ED in 2022/23, of which 91% did not require specialist paediatric input and were treated in the Urgent Treatment Centre (UTC) or by ED staff. Over that period 2.5% (341), which is an average of 3 to 4 children per day, were transferred to the assessment unit, and on average about 1 child per day was subsequently deemed as needing admission (i.e. needing a bed for inpatient treatment) and so were transferred to Kipling Ward at the Conquest Hospital site.

Reasons for change

15. The Board heard that hospitals similar to EDGH, without in-patient wards, usually co-locate assessment units or areas for urgent paediatric service within their Emergency Departments to improve access, speed of service and allow closer interaction and support between the paediatric and ED teams. The location of the SSPAU away from ED, and the limited hours of operation, constrained its ability to support urgent care at EDGH, which is mainly delivered in the UTC and ED.

16. The rationale for the changes has been stated by ESHT as being:

· The current location is not fit for purpose to meet the needs of the patients.

· It ensures that the right skills are available to meet the needs of patients and be available for the hours of day which fit the pattern of demand.

· The SSPAU was heavily reliant upon locum/bank staff, putting the sustainability of the service at risk.

· The inability to maintain clinical skills with low volumes of activity.

· There is an infection control risk through mixing urgent and planned care.

17. The Trust Board and Executive Committee approved the changed model on the basis that:

· it can be implemented safely and the Quality Impact Assessment (QIA) has been completed and approved.

· it improves patient experience and care for urgent pathways.

· there will be appropriate locations for the outpatient type work carried out at the SSPAU.

· that ESHT can provide suitable support for paediatric surgical care at EDGH (given the latest recommendations for hospitals without inpatient facilities).

· that it improves overall sustainability and use of resources longer term.

· that a more suitable area for Paediatrics in ED is provided.

18. The Review Board understands that the Trust’s vision is to create a more effective and sustainable urgent care model for EDGH, providing better patient experience and flow at the “Front Door”, whilst supporting sustainability for the wider Acute Paediatric service and aligning investment to the Trust’s long-term vision for a new hospital with an integrated emergency department.

Review Board Findings

Engagement with HOSC

19. The Board understands that ESHT started considering options for making changes to the paediatric services at EDGH in May 2023. A briefing was provided for the Chair in July 2023 and a briefing note was provided for HOSC members on the changes prior to the HOSC meeting in September 2023. A formal report was considered by HOSC at the committee meeting held on 14 December 2023.

20. The Review Board found that the changes to the Paediatric services were more far reaching than it appreciated from the briefing note and report to HOSC. Although neither NHS Sussex as commissioners, nor ESHT as providers, considered the proposed changes to constitute a ‘substantial variation’ in health services, the Board believes the level of public interest demonstrates the need to formally engage with HOSC on such changes.

21. The Board therefore considered that it would be helpful in future for HOSC to be formally informed of service changes at an earlier stage with more information, so that it can work together with the Trust particularly where there may be a high level of public interest in the service. In this case, having a fuller initial report may have been helpful to provide a good picture of the changes and their potential impact, which may have helped to re-assure members of the public about the nature of the changes.

Recommendation 1

The Board recommends that ESHT engage at an earlier stage with HOSC on any future service changes, particularly where there might be public interest in the service in question.

Patient Safety

22. The Review Board has heard evidence from a number of sources, including the Chief Medical Officer, divisional staff (including consultant paediatricians), Emergency Department staff and nursing representatives who all consider the new model to be safe. The Chief Medical Officer, who has corporate responsibility for patient safety, has made it clear in evidence to the Board that he would not have allowed the new model of care to be implemented if he did not consider it to be safe. He also considered the new model to be sustainable.

23. The Board also heard that there is an existing policy and procedure in place for children who come into the ED who may become critically unwell, which operates well. This is not a common occurrence as more seriously ill children are directly taken to the Conquest hospital site by ambulance, but may occur where parents bring their children into the ED.

24. The Board heard that there are weekly patient safety meetings and there had been no safety incidents reported in the first four weeks the new model had been operating. The new model is also being formally monitored and reviewed at weekly senior management meetings.

25. Based on the evidence heard by the Board it is satisfied that the new model of care is safe and is being monitored regularly. Later sections of this report examine in more detail some of the concerns expressed about the new service model including staffing and Paediatric consultant oversight and access.

Patient Care and Experience

Patient care and experience

26. The Board heard evidence from Divisional staff that the key differences under the new model are that it is Advanced Paediatric Nurse Practitioner (APNP) led rather than a Paediatric consultant led service. In addition, the location and type of facilities to assess and treat urgent and emergency care patients that require paediatric specialist input have changed and they will be located in a dedicated area adjacent to the Emergency Department (ED) and not in a separate assessment unit (SSPAU) located away from ED.

27. The intention of the new model is to ensure children and young people are seen by the right medical professional with the right medical expertise, at the right time and in the right place. It was stated that, as the dedicated paediatric unit will be open for longer hours and is also intended to be open at weekends under the new model, it will improve access to services on the Eastbourne site for local families.

28. At the time of the review, the new model had already been operated 7 days a week for 2 weeks and the aim is to have a consistently 7 day a week service as soon as possible. However, this is dependent on increasing staffing so could not be guaranteed at present.

29. The Board were told that APNPs are experienced, highly qualified and experienced staff equivalent in the relevant training to a Registrar doctor, and are more qualified and experienced in paediatrics than Senior House Officers (junior doctors). There is access to Paediatric consultant advice over the telephone 24 hours a day, 7 days a week if input is needed from a Paediatric consultant. When outpatient clinics are running, Paediatric consultants are on-site and available to give advice if necessary and the Review Board understands that outpatient ‘hot clinics’ are being provided for urgent referrals. Out of hours, when paediatric outpatient clinics are not running, there are procedures in place to ensure a Paediatric consultant can be on site within 60 minutes to attend a critically unwell child, but there are emergency care physicians on site 24 hours a day, 7 days a week and critical care consultants, in line with ESHT’s existing policy.

30. The Board also heard that ED doctors and consultants typically will have approximately six months of paediatric medicine experience as part of their training, either with ESHT or at a tertiary centre. They have all received paediatric emergency life support training.

31. The Chief of Urgent Care Division told the Board that early experience of the new model suggests that it is enabling children and young people who present at the ED to be seen more quickly. Children and young people presenting at ED are triaged within 15 minutes either by the APNP (if not dealing with another patient) or by ED staff. This can mean patients are seen and treated quicker under the new model, as it skips over a stage where a patient may be seen by a member of the ED team.

32. The number of 4 hour waiting time breaches has been reduced and the new model is improving patient flow through the ED. Therefore, there are wider patient benefits in having the dedicated paediatric staff in ED as it is relieving the pressure on ED staff and the GPs in the Urgent Treatment Centre (UTC). There has been positive feedback from members of staff in ED about how this is working well for the children attending ED.

33. The Board heard from Divisional staff that early data from the operation of the new model indicates more patients are being seen by paediatric specialists, either APNPs or Registrars. The Divisional Director outlined that in December 2023 under the old model, of the 200-270 patients attending ED per week, 0.52% - 3.0% were seen by a Paediatric consultant. Under the new model in the four-week operating period from 8 January 2024, 37% - 42% were seen by a paediatric specialist. The Board noted that this is not a direct comparison as the two models operate in different ways, with smaller numbers of children being referred to the SSPAU under the old model, compared with a greater proportion seeing and APNP or Registrar in ED under the new model. The Divisional Director also commented that initial data suggests patients are being seen and treated more quickly under the new model, which general research indicates can lead to better outcomes and patient experience.

34. The Board noted that the first 4 weeks of operation of the new model may not be typical, and care needs to be exercised in drawing conclusions about its impact on patient care and experience. During this time the SSPAU was open in shadow form and there was a Paediatric consultant available on the rota. In the Board’s view, more data will be needed over a longer period of time to establish the impact of the new model (see paragraphs 77-80 below regarding monitoring and review).

Summary

35. The Review Board considers that on balance, the new model of care does not have a negative impact on patient care in general and has the potential to improve patient care and experience for most patient groups, but more data is needed to confirm and evidence this. However, the Board does have some concerns about staffing sustainability and Paediatric consultant presence on the EDGH site, which are covered in more detail in the sections below. It also has some concerns about how the needs of those children with complex needs will be met under the new model.

Facilities in Dedicated area for Paediatric Services

36. The Board heard that there is a dedicated space adjacent to the ED which will be developed solely for the use of paediatric patients. It has a waiting area, an assessment area and 4 bays for observations or treatment which are separated by curtains. This has the capacity to handle the average 3-5 patients per day that were seen by the SSPAU on the urgent and emergency care pathway. The Board understands that it is not intended that the new space will meet all the standards for an SSPAU, which were published by the Royal College of Paediatrics and Child Health in 2017, as the model of care has developed further since that time.

37. The dedicated paediatric area is safe and secure as it will be separate from adult facilities in ED. However, it will not meet all the ED standards for children due to the building constraints, but this is planned for in the longer term under the Building For Our Future (BFF), New Hospitals Programme, which can accommodate a custom built paediatric unit that will meet all the standards. The Board noted that the amount of space available in new facilities appears to be less than was available in the SSPAU, which also had play facilities and quieter areas for observation. The Board has been unable to visit the new dedicated area for Paediatrics in the time available but plans to visit when the new modular building is in place.

38. The Board heard evidence from the Divisional Director that there are plans to refurbish/refit the dedicated paediatric area once the new modular building is ready for use around 8 March 2024, and GPs and ED staff will vacate the currently shared space and adjacent rooms to enable the refit to take place. ESHT will use feedback and recommendations from Young Healthwatch, who visited the paediatric area at the Conquest site to help design the new space at EDGH. However, it might not be possible to involve children and their families directly in the design of the new space at EDGH due to time constraints.

39. The Board heard in evidence from the East Sussex Parent Carer Forum (ESPCF) that there are concerns about the existing space in ED and the design of the new dedicated paediatric area. The current arrangements present challenges for children with sensory needs and parents who may have accompanying children, which will need to be taken into account. There is also a requirement for some provision for clinically vulnerable children, who may need to wait and be seen in areas separate from children presenting in ED with infectious diseases. The Board suggests that ESHT work with the ESPCF to address these concerns when designing and fitting out the new dedicated paediatric area.

40. The Board also heard that GPs moving into the new modular building will vacate two consulting rooms near to the dedicated paediatric area (consulting rooms 1 and 2). The Board noted that there may be opportunities to use these consulting rooms flexibly if there was a need for more private, quieter or separate areas for paediatric patients (e.g. for patients with mental health needs). The Board also heard that play facilities are available for children attending outpatient appointments and a play worker will be available to visit children in different parts of the hospital if needed.

41. The Review Board understands that the SSPAU located in the Scott unit is now closed and there are emerging plans to utilise this space for paediatric services. The Board would support the use of this space for paediatric services if there are opportunities to provide facilities for planned paediatric care activities.

Recommendation 2

The Board recommends that ESHT involve staff and representative groups including Healthwatch and the East Sussex Parent Carer Forum in the design and fitting out of the new dedicated paediatric space where possible, to ensure it is child friendly, child safe and meets patients’ and their families’ needs.

Recommendation 3

The Board recommends that Healthwatch and Young Healthwatch be asked to visit and assess the new dedicated paediatric space and service once it has been completed.

Recommendation 4

The Board recommends ESHT investigate developing the space in the Scott Unit for facilities for planned paediatric care activities.

Clinical Pathways

42. The Review Board explored whether and how the care pathways for patients would change under the new model, including for planned care, GP referrals, urgent care, mental health needs and social care medical examinations.

Planned Care

43. The Board heard evidence that the Outpatient clinics and day case minor surgical procedures are unchanged by the new service model. The majority of planned care activity and procedures previously undertaken in the SSPAU under the old model will now be undertaken in outpatients.The staff time of Paediatric nurses for planned care in outpatients is arranged around the planned care activity (e.g. if they are needed for a particular clinic or planned activity).

44. For specific patients and families with long term or multiple conditions, ESHT will wrap care around the patients with individualised care plans for planned care. It is hoped more of this will be home based care (e.g. provided by community teams and through initiatives like Virtual Wards) and the Board was assured by ESHT that there is no intention to transfer long term planned paediatric care to the Conquest. However, the Board is concerned that under the new service model there is a potential that a small number of families who access planned care services for children with complex needs may be moved to the Conquest in order to continue to offer the individualised care pathways for those children with complex care needs.

45. The Board heard evidence from the ESPCF that there had been little communication with parents and carers about the new pathways. In particular, it was unclear what the arrangements were for children and families with complex needs who previously had ‘open access’ arrangements in place to bring their children into the EDGH. The Board considers that it is essential that the parents and carers of children who are regular users of the services are informed about any changes in the pathways and what it means for them.

46. The Board notes from the Equalities and Health Inequalities Impact Assessment and evidence given by the Divisional Director that there will be a “hot clinic” set up on a daily basis at EDGH with a consultant level paediatrician to provide cover for families who may require urgent access to a Paediatrician.

47. However, following confirmation by the Trust, the Board understands that not all the clinical pathways for planned care have been finalised and are in place. The Board is concerned that not all of the pathways were finalised before the new model was rolled out at the beginning of January and would like to see documentary evidence that the outstanding pathways have been agreed and implemented, with a timeline to be shared with HOSC as soon as possible.

Recommendation 5

The Board is concerned that many of the pathways were not finalised before the new model was rolled out and recommends that ESHT finalise the outstanding planned care pathways as soon as possible and that copies of the new clinical pathways documentation are provided to HOSC once finalised and agreed with staff.

Recommendation 6

The Board recommends that additional communications are provided to parents and carers that are affected by the any of the changed pathways as a matter of urgency, so that families and their children who are regular users of the services at EDGH understand how the changes may affect them.

GP Referrals and Advice Triage Telephone Hot Line

48. Under the new service model, GP referrals are handled in the same way as previously, by a Paediatric consultant who holds the GP triage phone. A Paediatric consultant of the day holds this phone and provides advice on the best treatment and on referrals for GPs and anyone in the community teams who requires advice. This is a single hotline for ESHT referrals rather than specific to one hospital. Patients requiring face to face care will be directed to the location that can best meet their needs. This is sometimes dependent on the length of stay required and whether they will need to be admitted into hospital for treatment. The triage Paediatric consultant is able to provide input into, and advise on, the treatment plan for patients at this point in the pathway.

49. Patients referred to the ED at EDGH will be seen by APNPs who can also speak to the Trust’s on-call paediatric consultant (a separate consultant from the one holding the triage phone) for advice over the telephone. ESHT does not anticipate that more children will be referred to the Conquest for assessment and treatment via this pathway under the new model.

50. The Board heard anecdotal evidence that there was some confusion about the new service model amongst GPs and the changes that were being made. ESHT confirmed to the Board that no changes were being made in the GP referral process, and communications about the service changes have been included in the Integrated Care Board (NHS Sussex) newsletter that is sent out to all GPs.

Urgent Care – Paediatric consultant input

51. Under the new model patients who need to see a paediatric specialist will be seen by an APNP or Registrar, rather than a Senior House Officer or Paediatric consultant as under the old model. Some concerns have been expressed by Board members, staff, and members of the public about not having a Paediatric consultant available on site at EDGH to provide Paediatric consultant input for children presenting in ED.

52. ESHT has given assurances that Paediatric consultant input and advice is available over the phone from the on-call paediatric consultant 24 hours a day and seven days a week, and from Paediatric consultants undertaking outpatient clinics at EDGH if necessary. ESHT have stated that by comparison, under the old model, there was no Paediatric consultant on site for two thirds of the time. However, the Board remain concerned about having sufficient Paediatric consultant presence and input at the EDGH site in the new service model.

53. The Board considered that a solution to this would be to permanently locate the Paediatric consultant who holds the GP triage phone at the EDGH site, so they are also available to support the APNP and Paediatric nurses in ED if consultant level opinion or input is required for patients being seen in the new paediatric facilities in ED. This would also provide additional reassurance whilst the new model becomes established.

Recommendation 7

The Board remain concerned about having sufficient Paediatric consultant presence at the EDGH site and recommends that ESHT permanently locates the Paediatric consultant staffing the GP triage phone at the EDGH site to provide a level of consultant input into the new service model and to provide additional assurance to address concerns about the level of consultant presence in the new model.

Transfers to the Conquest Hospital

54. One of the concerns expressed by staff and members of the public is that there may be a need for more transfers of patients who come into the ED at EDGH due to not having input from a Paediatric consultant in the new model. The Head of Division told the Board that there was not expected to be a change in the number of patients needing to attend the Conquest Hospital and there would be sufficient capacity there, if there were any minor changes in patient numbers.

55. The Board heard that there are at present a small proportion of patients who present at EDGH who are transferred to the Conquest Hospital in Hastings for treatment. Early data suggests there has not been an increase in the number of transfers and there may in fact be fewer patients being transferred under the new model. The Divisional Director advised the Board that roughly 4-6% of patients were transferred to the Kipling ward at the Conquest prior to the new model being implemented during December 2023. In four weeks under the new model 3-4% of patients were transferred to Kipling from ED at the EDGH.

56. However, the new model had only been in operation for its first four weeks at the time of writing. During this ‘soft launch’ period a consultant Paediatrician was available on site to assist if needed and the SSPAU had been kept open in shadow form, although no patients needed to be transferred there. There are also seasonal differences in the number of patients seen in ED related to infectious diseases which may impact on the figures.

57. It has, therefore, been difficult at this stage for the Board to assess whether there will be a change in the number of patients transferred to the Conquest Hospital for treatment under the new model. A longer period of time and more data are needed to evidence the impact of differences in the new service model. Healthwatch has suggested that, in its view, the new model should ideally be monitored and assessed over a twelve month period (see recommendation in Monitoring and Review section below, paragraphs 77-80).

Children’s Social Care Medical Examinations

58. Paediatric consultants are required to carry out medical examinations for children’s social care and child protection matters. Concerns were expressed that, under the new model, a Paediatric consultant would not be available at the EDGH in a timely way to carry out these medical examinations. The Board were given assurances by the Head of Division that a Paediatric consultant will be available on site at the nearest or most convenient hospital location agreed with the social worker to undertake children’s social care medical examinations.

Mental Health Needs

59. The Board heard that the EDGH will continue to have the same Child and Adolescent Mental Health Service (CAMHS) nursing availability at EDGH under the new model (NB this service is provided by the Sussex Partnership Foundation Trust). Under the old model the SSPAU was not usually involved in supporting children and young people with mental health needs because those needing a longer course of treatment would be admitted to Conquest Hospital. Very occasionally children would come to the unit at EDGH before going on to the Conquest Hospital, but for more significant needs (e.g. overdoses) children would go to the Conquest directly.

60. The Board considered that it would be helpful to identify quieter areas in the new facilities that could be used if needed for children presenting with mental health issues.

Recommendation 8

The Board recommends that ESHT consider identifying a suitable space that could be used for children and young people presenting with mental health issues within the facilities in ED.

Staffing

61. The Board examined a range of evidence to understand the level of training and expertise of the staff operating the new model and the difference there might be between this, and a Paediatric consultant led model. The Board also examined whether there were enough sufficiently qualified and experienced staff to operate the new model sustainably.

62. Under the old model the SSPAU was staffed by a Paediatric consultant, a Senior House Officer, two Paediatric nurses and a Healthcare Assistant for urgent and planned care. The new model for urgent care is staffed by an APNP or Registrar and two Paediatric nurses based in ED. There is ongoing support from an on call Paediatric consultant located either at the EDGH or the Conquest provided over the phone and there are Paediatric consultants on site at EDGH when paediatric outpatient clinics are running.

Advanced Paediatric Nurse Practitioners (APNP)

63. The Deputy Chief Nurse provided evidence to the Board on the role, qualifications and experience of APNPs. All APNPs undertake a Masters Degree level, two year training programme that covers the technical aspects of the role as well as practical exams and tests. Training is provided on the job with appropriate levels of supervision from a medical doctor.

64. APNPs in their role are able to:

· see and assess patients;

· have advanced physical diagnosis skills;

· carry out differential diagnosis,

· refer for tests and review diagnosis;

· develop a treatment plan; and

· review the treatment plan.

65. APNPs work at the same level as a Registrar. APNPs have a holistic approach to patient assessment, treatment and review which, in the Deputy Chief Nurse’s view, is good for patient care and experience. All APNPs are trained in Advanced Paediatric Life Support which is the same level as Paediatric consultants (and APNPs provide this training to consultants).

66. The Board heard that in terms of skills and expertise, APNPs can undertake tasks that that a Senior House Officer or Paediatric nurse cannot. For example, an APNP can carry out a lumber puncture; in Brighton APNPs undertake the care of neonatal babies (who can be some of the most seriously ill children) and APNPs accompany unwell children when they are transferred to tertiary hospitals in London for treatment.

67. The Board heard evidence from the Chief of Division and Divisional Director that the majority of children and young people presenting at ED do not need to be seen by a paediatric specialist and can be assessed and treated by the ED staff and GPs in the UTC. Under the new model more children presenting at ED are able to be seen by the APNPs and Registrars who are located within the department. The new model of care is considered safer as it introduces more hours of paediatric expertise, provided by APNPs and Registrars.

Sustainability of Staffing

68. The Board heard from the Associate Director of Nursing (Womens & Children) that there are currently three qualified APNPs with a fourth due to qualify at the end of March 2024. The Trust is recruiting more APNPs into the role, which is attractive as it offers good career progression and training. In addition to APNPs the Trust has recruited Registrars, who are middle grade doctors, to initially fill the other posts needed.

69. The Associate Director of Nursing (Womens & Children) told the Board that APNP recruitment is ongoing on a rolling programme. The aim is for a staffing complement of eight full time equivalent (FTE) APNP posts. Most recruitment is internal from existing staff who are already qualified and experienced nurses. The Deputy Chief Nurse outlined that APNP trainees will not be new inexperienced staff, but will often be nurses who have already worked in paediatrics for a long time. So, they already have a level of expertise that can be over a decade long.

70. External recruitment of APNPs is more challenging as qualified APNPs do not tend to leave their roles. The Head of Division considered that ESHT have enough staff at present to operate the new model and will look to build the number of staff in the APNP role.

71. Based on the evidence heard by the Board, there appear to be enough suitably qualified staff to operate the new service model at present by using a combination of APNPs and Registrars. However, the Board noted that there are only three qualified APNPs at present with another due to qualify at the end of March. EHST has recently recruited a further two trainee APNPs to make up a complement of six full time equivalent (FTE) APNP posts.

72. Given that the Board heard that it is challenging to recruit APNPs externally, and that training staff internally to fill APNP roles can take up to two years, there is a question as to what will happen to the sustainability of the new service model if one or more of the existing qualified APNPs were to leave or go on long term sickness/absence from work, leaving a smaller number of qualified staff and staff in training.

73. The Board understands that a full complement of staff will be needed to operate the new service model consistently for 7 days a week. Consequently, the Board has some concerns about the resilience of the staffing of the new service model.

Recommendation 9

The Board recommends that ESHT reviews and expands the number of trainee APNP roles if possible, to provide greater resilience and assurance for the operation of new service model.

Travel and Access

74. Existing support is provided to patients and their families who may need to travel to the Eastbourne or Conquest hospital sites through the Patient Transport Service (PTS) and use of ESHT’s discretionary taxi scheme. Signposting, advice and help with understanding eligibility criteria for the PTS is also provided.

75. The Board heard that in individual cases, where appropriate, the discretionary taxi scheme can be used to support disadvantaged families with travel to the hospital sites. This would apply in circumstances where families need to travel to the Conquest site from Eastbourne (and other areas). Children transferred from EDGH ED to the Conquest would go via ambulance.

76. Given that the vast majority of patients are expected to see no change to the location they access services, and that additional transfers are likely to be by ambulance, the Board was satisfied that there is sufficient travel and access support in place for any patients and their families who might be affected by the service changes. The Board considers that it would be beneficial for ESHT to actively promote the existing travel and access support that is available for patients and their carers, and to consider the use of a Travel Liaison Officer role to support patient travel and access (which was agreed as part of previous reviews for Cardiology and Ophthalmology). It would also be helpful for ESHT to provide monitoring information on any additional travel support that has be provided as part of the operation of the new service model, and any increases in the number of children from the Eastbourne area going directly to other hospitals ED for their treatment.

Recommendation 10

The Board recommends that ESHT promote the travel and access support that is available to patients and their families, who may be affected by changes in the new model of care, and consider the use of a Travel Liaison Officer role to support travel and access arrangements.

Monitoring and Review

77. The Board heard that there is extensive monitoring in place for the new service model at a number of levels. The Chief Executive Officer outlined that there are:

· Weekly monitoring reports on the new service to the Executive Team which include information such as patient numbers, wait times, transfers to the Conquest, and incident reporting.

· Monthly reporting to the Integrated Performance Review meetings. These are monthly reports to the Executive Team which cover quality, access and response, finance, and workforce.

· Monthly reports to the Quality and Safety sub-committee of the Trust Board.

78. In addition, ESHT meets with NHS Sussex on a regular basis to discuss any quality concerns. An independent report is also being commissioned by ESHT on the new service model which will be shared with HOSC when it is available. It is hoped this will be by the end of February, but this will depend on the availability of a suitably qualified person to carry out the review who is not part of the Trust. ESHT will also be looking at patient feedback from the Friends and Family survey information, complaints and contacts made via the Patient Advice and Liaison Service (PALS) service, as well as feedback from the APNPs and other staff teams.

79. The Board considered that more data over a longer period of time is needed to confirm and evidence the impact of the new model on patient care and experience. Healthwatch East Sussex has also recommended that ESHT clarifies the metrics and milestones used to determine the effectiveness of the changes to paediatric care at EDGH with HOSC and Healthwatch, and provide an update on their status twelve months after any changes are implemented. The Board considers that this period of time would allow for any seasonal variations in patient numbers and variations in staffing to be reflected in the data.

80. The Board has been given a commitment by the Trust Chief Executive that ESHT is committed to carefully monitoring the new service model, and will advise HOSC immediately of anything that is not working well and make adjustments to the service model as necessary.

Recommendation 11

The Board recommends that ESHT clarifies the metrics and milestones used to determine the effectiveness of the changes to paediatric care at EDGH to HOSC and Healthwatch.

Recommendation 12

The Board recommends that ESHT provides an update report to HOSC on the operation of the new service model at the 6 June 2024 and 12 December 2024 HOSC meetings.

Recommendation 13

The Board recommends that HOSC works with Healthwatch to monitor and review the operation of the new service model.

Conclusions

81. Overall, having considered a range of evidence in detail, the Board considers that the new service model for paediatric services at the EDGH is safe, does not negatively affect patient care for most patient groups, and has the potential to improve patient care and experience in general. However, the Board has some concerns about the staffing sustainability of the new model, the clinical pathways for planned care including those for children with complex needs, and would like to see adjustments made to address concerns regarding the level of Paediatric consultant input at the EDGH site.

82. The Board would also like to have more data over a longer period of time to assess the impact of the new model on patient care and experience, and has suggested HOSC work with Healthwatch to monitor and review the new service over the next twelve months. ESHT have given a commitment to the Board that they will carefully monitor the new model of care and make changes to the model if necessary.

Appendix 1:

Scope and terms of reference of the review

The Review was established to consider and make recommendations on the following.

The scope of the review focussed on the changes to the various patient pathways for paediatric services at the Eastbourne District General Hospital (EDGH) and in particular the impact on urgent and emergency care pathways, including:

· What has changed and the impact of the changes on patient safety (particularly for those children whose pathway is different from the previous service model);

· The impact on patient care and experience (including the facilities for the treatment of children);

· Travel and access impacts of the service changes; and

· Staffing and sustainability of the services (including operational hours, and Paediatric consultant cover/supervision).

The lines of enquiry for the review included:

What are the reasons behind the changes and will the service changes lead to an improvement in patient care and experience?
Will the new service model be sustainable and what days/hours will the new services be provided on?
What are the impacts on patient safety?
What level of Paediatric consultant cover will there be for the new service and in particular for urgent and emergency care pathways?
Is there sufficient, suitably qualified staff available to provide the service sustainably, including the number of Advanced Paediatric Nurse Practitioners (APNPs)?
Will the changes result in more children having to travel to the Conquest Hospital for treatment (including conveyances by ambulance) and what are the patient numbers that will be affected by the changes?
How will families without access to a car or lower income families be supported if they need to travel to the Conquest Hospital?
What will the new facilities next to ED consist of and will they be ‘child friendly’? (capacity, design etc.)
Will there be sufficient space/capacity for the planned care activities which are being moved from the SSPAU? (e.g. in outpatients)
How will the new service model be monitored and reviewed to ensure it is delivering the services to the standards expected?
Will the changes have an impact on the provision of children’s social care child protection same day medical assessments?

Desired Outcomes

To provide assurance that the proposed changes will not have a negative impact on patient safety, patient care and experience.
Provide recommendations for measures to mitigate any adverse impacts and improve patient care/experience within the context of the proposed changes to services.

Matters Outside the Scope of the Review

Service changes that have taken place as part of the previous reconfiguration of Paediatric services.
Internal staff whistle blowing policies and matters covered by internal staff consultation, HR, grievance or dispute resolution procedures.

Board Membership and project support

Review Board Members: Councillors Christine Robinson (Chair), Abul Azad, Colin Belsey and Alan Shuttleworth.

The Project Manager was Martin Jenks, Senior Scrutiny Adviser with additional support provided by Parick Major, Scrutiny & Policy Support officer.

Review Board meeting dates

05 February 2024

09 February 2024

12 February 2024

23 February 2024

Witnessesproviding evidence:

The Board would like to thank all the witnesses who provided evidence in person:

East Sussex Healthcare Trust (ESHT) officers

Joe Chadwick-Bell, Chief Executive Officer

Dr Matthew Clark, Consultant Paediatrician and Chief of Division Women, Children, Sexual Health and Audiology. National Specialty Advisor Children and Young People, NHS England.

Kaia Vitler, Divisional Director Womens & Children (W&C).

Dr Simon Merritt, Chief Medical Officer

Angela Colosi, Deputy Chief Nurse

Mark Standen, Associate Director of Nursing (Womens & Children)

Dr Jose Almaraz, Chief of Division Emergency Care

Voluntary and community sector organisations

Healthwatch East Sussex (HWES)

East Sussex Parent and Carer Forum (ESPCF)

Evidence papers

Item	Date
ESHT Briefing Paper to HOSC dated 15 September 2023.	September 2023
ESHT report to HOSC on 14 December 2023.	December 2023
HOSC Minutes of the Meeting held on 14 December 2023	December 2023
Letter to HOSC from ESHT Chief Executive dated 20 December 2023	December 2023
ESHT Executive Options Paper – Paediatric Service Change and Improvement, including Case for Change.	May 2023
Written Submissions from Members of the Public and Staff	Various
ESHT Equalities and Health Inequalities Impact Assessment	January 2024
ESHT Floor Plan of New Dedicated Paediatric Area	February 2024
HOSC: Update on Paediatric Pathway changes at EDGH and impact.	February 2024
Healthwatch EAST Sussex response to HOSC regarding Changes to Paediatric Services at EDGH	January 2024
Standards for Paediatric Short Stay Assessment Units (SSPAU). Royal College of Paediatrics a Child Health.	March 2017

Contact officer: Martin Jenks, Senior Scrutiny Adviser Telephone: 01273 481327
E-mail: martin.jenks@eastsussex.gov.uk

Appendix 2

Statement from Cllr Alan Shuttleworth regarding the Report of the Review Board

I am in agreement with the bulk of the recommendations, which I have contributed to, but I am still unconvinced about effects of the new model, having listened to all the witnesses.

I wish to record as part of the Report findings that I am not in agreement with the statement that the new model “does not negatively affect patient care.” Further, I believe that the changes will lead to more families with children needing to travel to the Conquest hospital in Hastings to access care.

The review recognised that some children with complex needs would likely be transferred to the Conquest. The new model’s reliability on APNP staff rather than Paediatric Consultant availability will inevitably lead to more transfers as there will be more access to paediatric consultants care in Hastings.

I believe that the catchment area served by Eastbourne District General Hospital warrants an improved Paediatric Service, a Consultant-led service supported by APNP staff. The paediatrics service has been downgraded overtime but this review of the service should have been an opportunity to reverse the trend.

The Board has heard evidence which has demonstrated the inadequacies of the consultations with staff, patients and the wider public over the proposed changes. The Health and Overview Scrutiny Committee were right to request a halt in the implementation. The changes were introduced without agreement on the planned care pathways for all patients. The evidence from the East Sussex Parent Carer Forum showed that individual families had been kept in the dark over changes.

The loss of the Short Stay Paediatric Assessment Unit has already been felt, and the proposed new space by the emergency department will not be large enough to replicate the service. There is a need for a separate waiting area for children, especially those who are vulnerable to infection or needing separation for observation or a calm area separate from the emergency area. Despite launching the changes, the new modular unit is still not in place. It may have some benefits but will also have shortcomings in terms of available space. What is needed is a custom built child friendly paediatric unit with sufficient space to offer all aspects of care and treatment for children and young people and to avoid a mix with the adult emergency patients. This was promised in the form of a new hospital which has never materialised.

The travel and access support for those families who already need to travel to the Conquest hospital in Hastings or elsewhere will be more in demand, and needs to be transparent and available for those who need it.

The changes in Paediatric Services at Eastbourne District General Hospital have been rushed in and have left some staff, patients and the wider public questioning if they are going to result in a further downgrading of this department, and a risk in the sustainability of this staffing model.