Agenda item

24.1     The Committee considered a report on planned changes to the delivery of paediatric services at Eastbourne District General Hospital (EDGH). Joe Chadwick-Bell, East Sussex Healthcare NHS Trust (ESHT) Chief Executive recognised that the planned changes would be a change in working practices for some staff at EDGH, and noted that there had been media coverage and public representations made to the Committee that related to the planned changes. Joe Chadwick-Bell and Dr Matthew Clark, Consultant Paediatrician and ESHT Chief of Women and Children reiterated what was in the report, that there would be no planned activity moves from the EDGH to the Conquest Hospital in Hastings.

24.2     The Committee asked why NHS Sussex did not consider the planned changes to be a substantial variation.

24.3     Jessica Britton, NHS Sussex Executive Managing Director, East Sussex responded that NHS Sussex did not view the planned changes to be a service change as they were related to how services were organised within the hospital. NHS Sussex anticipated that the changes would increase access and hours of access for children and young people, and therefore not a substantial variation.

24.4     Cllr Alan Shuttleworth shared his view that due to a lack of detailed information having been provided, the implementation of planned changes should be paused until there had been a review and a full consultation with all stakeholders. Cllr Shuttleworth also shared his concern that an unintended consequence of the planned changes could be that more children and families have to travel to the Conquest for treatment.

24.5     Joe Chadwick-Bell recognised Cllr Shuttleworth’s request, and reiterated that the same activity for planned care or urgent care would still come to Eastbourne, and there were no changes that would lead to children going to the Conquest. She emphasised that it was an internal reorganisation of where children would be seen within the hospital. The first stage of the planned implementation was of urgent care and was due to start on 8^th January 2024, and the second stage was of elective care and would begin in February 2024. Dr Matthew Clark noted that there had been a lot of discussions with staff and other stakeholders in the lead up, and no patient safety issues had been raised despite some differences in views over the proposed model of care. Rotas were in place to implement on 8^th January and to move away from the planned date would be disruptive and operationally difficult.

24.6     The Committee asked for more detail on how planned care and urgent care pathways would change when the planned changes were implemented.

24.7     Dr Clark explained that under the current model most children who presented at the EDGH Emergency Department (ED) would be triaged and the vast majority directed to the Urgent Treatment Centre (UTC) as they did not require input from a paediatric specialist. Any children who could not be treated at the UTC would be seen in the ED by emergency physicians, and only if they could not solve the issue would a child then be referred to a paediatric consultant at the Short Stay Paediatric Assessment Unit (SSPAU). The changes planned from 8^th January would see an Advanced Paediatric Nurse Practitioner (APNP) located in the paediatric department, so that children who could not be cared for in the UTC or ED would immediately see a paediatric specialist. The APNP would make an assessment and either begin treatment or, as was currently the case, transfer the child to the Conquest Hospital if they required in-patient care. The proposed changes were therefore designed to concentrate expertise at the front door of the hospital, allowing for children to be assessed quicker. ESHT were keen to implement the model as they thought it to be more efficient and they viewed it as an improvement in service.

24.8     The Committee asked for clarity if it was only the location of care that was changing as part of the planned changes.

24.9     Dr Clark answered that both the location and the staffing model were changing. The SSPAU was currently staffed by a paediatric consultant, a paediatric SHO and paediatric nurses. Under the new model an APNP would work with paediatric nurses in the ED. Dr Clark noted that the majority of children at EDGH did not need consultant level input for their care. Joe Chadwick-Bell added that hospitals would regularly reconfigure their services to make best use of resources, and in this instance it was a case of the resource moving towards the child with services being provided close to the ED, rather than the child needing to move towards the resource as they currently did. At present 90% of patients are seen either in the Urgent Treatment Centre or the Emergency Department.

24.10   The Committee asked when the new unit would be in place, and how children would be cared for in the interim between the changes being implemented and the facilities set up.

24.11   As context to the changes, Dr Clark outlined that the SSPAU was not currently open for 14 hours of the day on weekdays (i.e. during evenings and the night) and not open at all on weekends at EDGH. Children come to the ED at Eastbourne 24 hours a day 7 days a week. When the SSPAU was closed there was not a pattern of problems, and only occasional patient safety incidents and complaints as would be expected for any healthcare service. Under the current arrangements there was a small paediatric assessment waiting room, one assessment room and a four-bedded room shared between paediatrics and emergency nurse practitioners who dealt with injuries of children. That would not change at the implementation date, but a new modular build would arrive in February as a dedicated paediatric area in ED. This area would have 5 spaces for children in total, including an assessment unit, and would have its own dedicated toilet facilities. Dr Clark explained that the estate at EDGH was not ideal for children and young people, but that as part of the New Hospitals Programme he would expect there to be dedicated paediatrics services at both EDGH and Conquest that met all national standards. This was not currently possible with current resource, but ESHT wanted to have the appropriate models of care in place so that services could then move into the right resources when they were available.

24.12   Joe Chadwick-Bell noted that the purpose of the report had been to reassure the Committee that no cases would be transferred from Eastbourne to Hastings but accepted that the submitted report should have included more detail on the proposed changes.

24.13   The Committee asked if the Elective Care Hub at EDGH would receive some paediatric cases when it opened.

24.14   Joe Chadwick-Bell explained that children who had operations would currently recover in theatres or the day surgery unit and there were no immediate planned changes with this, but activity would move to the day surgery unit when it opened in approximately 18 months.

24.15   The Committee asked how parents and carers who were regular users of the service had been consulted on the proposed changes.

24.16   Dr Clark explained that there had not been a full public consultation as there was no expected change for almost all service users and so it would not have been a good use of people’s time to fully consult. There were a small group of children and young people with very complex medical needs who regularly used the service, and plans for continuity of care for each of those families were being made on an individual case-by-case basis.

24.17   The Committee asked whether children’s social services, ED, mental health services and GPs had been consulted ahead of the proposed changes.

24.18   Dr Clark explained that main interaction between social care and acute paediatrics was with child protection medical examinations, and the commissioning arrangements for these were currently being reviewed, but the Trust was committed to always having a paediatrician available for those urgent examinations. Children’s social services would be engaged as part of those changes, but had not been consulted on the specific proposed changes at EDGH. He added for context, that the Trust is not closing paediatrics at Eastbourne and there will still be paediatricians and clinics on site. There had been close discussion with ED consultants and managers who welcomed the proposals. There was not expected to be a significant impact on GP referrals which would be managed in the same way, and the only change in this area would be that children who had same-day referrals to EDGH from GPs would be seen first by an APNP in ED, rather than a paediatric consultant. The Child and Adolescent Mental Health Services (CAMHS) liaison nursing at EDGH would remain unchanged, and the current SSPAU was not usually involved with children and young people with mental health issues because those needing a longer course of treatment would be admitted to Conquest.

24.19   The Committee asked what the anticipated impact on Conquest hospital would be as a result of the proposed changes.

24.20   Dr Clark explained that there was not expected to be a change in the number of patients needing to attend Conquest and there would be sufficient capacity if there were any minor changes in patient numbers. It was possible that once a seven-day a week service at EDGH was available that there could be fewer patients needing to go to Conquest.

24.21   The Committee asked why a previous briefing had suggested there would be 1-2 children a day needing to go to Conquest if the Trust was no predicting that no additional children would need to be transferred.

24.22   Dr Clark explained that the Trust had anticipated 1-2 children a day needing to move across to Conquest when the changes were initially proposed, and this was related to a specific elective medical test (Endocrine testing) that had been expected to move to Conquest. Subsequently the Trust learned that there were other hospitals that did that specific treatment in out-patients, so it was now no longer expected that children and families would have to go to Conquest for that specific test. He added that it was incredibly difficult to predict every possible implication, as it was not possible to know whether an APNP or a consultant was more likely to transfer a patient, but in essence there would be more hours of paediatric expertise at EDGH. Joe Chadwick-Bell added that there would be a consultant on-site at Eastbourne working in out-patients, and there would be a consultant available at the same times as present for the first 3 months during the implementation period, and changes could be made during that period if they proved to be necessary.

24.23   The Committee asked the times at which a paediatric consultant was currently on-site at EDGH, and whether a paediatric consultant would be on-site at EDGH at all times under the proposed changes.

24.24   Dr Clark explained that currently a paediatric consultant was on-site when the current SSPAU was open 9am-7pm on weekdays. This would not be the same under the proposed changes, as a paediatric consultant would instead be on-call at EDGH 24 hours a day, 7 days a week, but not necessarily on-site. In emergencies a consultant would be able to attend on-site at Eastbourne. APNPs at Eastbourne would be able to discuss cases with a consultant over a phone prior to having to make a referral. Joe Chadwick-Bell highlighted that for the first three months of the implementation of the proposed changes there would be a paediatric consultant on-site during daylight hours. After that period the urgent care service would be APNP-led and rotas were in place for the first three months.

24.25   Cllr Ballard noted that it could take more than half an hour to travel from the Conquest to EDGH, and explained that she felt the proposed changes provided insufficient cover in an emergency situation if a paediatric consultant was required.

24.26   Dr Clark responded that all APNPs had the same advanced paediatric life support training (EPALS (European Paediatric Advanced Life Support Skills)) as all paediatric consultants. There was an existing policy for supporting critically unwell children that presented to the ED at EDGH, where the emergency department consultant and the anaesthetic consultant were immediately available, and a paediatrician would be on-site within an hour. This system had been in place for five years with no reported incidents related to that. Under the proposed changes a APNP would also be immediately available to support, and it was the Trust’s view that a paediatric consultant was not a critical part of the immediate resuscitation team. Joe Chadwick-Bell added that ambulances would take children to Conquest in almost all cases, so the small number of emergency cases presenting at EDGH tended to be walk-in patients.

24.27   The Committee asked if there would be piped oxygen in the paediatric emergency unit.

24.28   Dr Clark explained that there wasn’t piped oxygen in the new assessment unit, but the current SSPUA did not have this either as critically unwell children would always be looked after in the resuscitation department where there was all the necessary equipment to support them.

24.29   The Committee asked whether staff rotas were in place for implementation and whether the whole rota could be covered by APNPs.

24.30   Dr Clark recognised that staffing was tight, noting that the current arrangements at the SSPAU relied at times on almost 20% locum shifts. The Trust felt they had enough staff to provide the service 5 days a week for 12 hours a day, as well as some weekends for the first few months of the new arrangements. There was a recruitment and retention programme to train and keep more APNPs at the Trust. Joe Chadwick-Bell added that the rotas were in place through January into to February, and they were still being worked on beyond that. It would be a combination of APNPs and registrars running the service while recruitment programmes continued to fill APNP vacancies.

24.31   The Committee asked for comments on the perceptions of some that the proposals were being rushed and whether this would reflect negatively on the hospital if the services were not sufficiently child friendly.

24.32   Dr Clark referred to previous comments that the present estate at EDGH was not ideal for caring for children and young people, and in the future that would not be the case.

24.32   The Committee asked whether ESHT had longer-term recruitment plans to address staffing shortages in paediatrics.

24.33   Dr Clark explained that ESHT were keen to train more APNPs from existing staff, which reduced the need for as many middle grade staff and allowed progression for current staff. Five people had already been through training to become APNPs and the Trust saw the future of children’s service at Eastbourne as being fronted by more advanced practitioners rather than doctors, and this was in line with the NHS long-term workforce plan. APNP training is provided through a Masters programme at London South Bank University funded by Health Education England and is a similar level to Registrars.

24.34   The Committee asked when ESHT expected they would not be experiencing staff shortages in this area.

24.35   Dr Clark responded that due to the small size of the team it was difficult to know when there would be comfortable staffing numbers, as it would only take one or two members of staff leaving to change this. From January there would be four APNPs, there was another one in training, and the Trust hoped to recruit two more trainees in the next year. The Trust has had APNPs in these roles for around the last 3 years. Training took about two years and staff in training received appropriate supervision throughout and newly qualified APNPs had a period of work at the Conquest under close supervision from paediatric consultants before they start practicing at EDGH.

24.36   The Committee asked how many paediatric consultants currently worked for the Trust and how many there would be following the implementation of proposed changes.

Dr Clark responded that ESHT had 15 paediatric consultants at present and did not anticipate that changing, although some of them also worked in community services. There would be some changes to consultants’ job plans and ways of working, but no expected change in headcount.

24.37   The Committee asked how many paediatric consultants were currently working and available at any given time given they worked across EDGH, Conquest and in the community.

24.38   Dr Clark responded that this varied between winter and summer. In summer there was a consultant on-site at Conquest for nine hours a day during weekdays, and six hours a day at weekends, and another on-call 24/7. Another consultant would be on-call for EDGH, who during the day would support triaging GP referrals, supporting the community nursing team and attending the ED in emergencies. A further consultant would also be on-call 24/7 to attend ED at EDGH in emergencies. During winter, in addition to this another consultant would be working at the SSPAU at Conquest to support the assessment of children during busier times of year.

24.39   The Committee asked why the proposed changes were being implemented in January if the building would not be in place until February and how the Trust would respond if the facilities were not in place when they expected them to be.

24.40   Joe Chadwick-Bell responded that the current service model was subject to short-term closures and that the Trust wanted to implement soon to provide a consistency of service across the busy winter period. The new rotas were already tried and tested as they were already in place at times when the SSPAU was not open. The proposed changes had gone through staff consultation, and there had also been some staff turnover through that consultation period and movement into community roles, so the rationale for the implementation was to have in place a consistent service model that would be easier to staff. The new facilities had been due to be in place in December but there had been access issues with how the new facility would be joined to the main hospital. She accepted that it would have been preferable to have the new unit in place for the beginning of implementation, but that staff rotas had already been agreed and the new unit was expected to be in place by February. In the meantime there were well-established and safe care pathways that were in place at the time when the SSPAU was closed, and if anything unexpected occurred this would be reviewed regularly by the Trust and adjustments could be made in discussion with the team. The Scott Unit remained available if necessary. Some care would also be provided by community teams, which is better for the patients.

24.41   The Committee asked if the main reason for the proposed changes were due to staffing issues.

24.42   Dr Clark responded that the primary reason for changes was to improve urgent care services for children in Eastbourne, and that is why the proposed model of moving services to the ‘front door’ was being implemented.

24.43   The Committee commented that the report presented to it had not provided sufficient information for it to properly evaluate the proposed changes, and suggested that the Trust provide a more detailed report for the Committee to consider.

24.44   Joe Chadwick-Bell responded that a substantial amount of work to analyse and prepare for the changes, although the purpose of the report provided had been to assure the Committee that the proposed changes would not result in a shift in activity to another site. ESHT viewed the proposed changes as internal ones about where children were seen on the current site, but recognised that there had been other representations raised on the issue. Joe agreed that further detail on the changes could be provided outside of the meeting.

24.45   The Chair commented that his view was that there should be a pause in the proposed changes until the HOSC was able to conduct a review, which would be presented to the March meeting.

24.46   Cllr Alan Shuttleworth commented that he felt there were many questions that remained which needed answering including more information on consultations that had taken place and staffing. He advocated a pause in any proposed changes until the HOSC was able to conduct a review and have a fuller report on the changes.

24.47   Joe Chadwick-Bell emphasised that ESHT was not moving any services from Eastbourne to Hastings. She did not commit that there would be a pause in the implementation of the proposed changes, but recognised that further information should be provided to HOSC.

24.48   Cllr Colin Belsey proposed and Cllr Alan Shuttleworth seconded the following RESOLUTION, which was agreed by the Committee:

1)    while accepting that it cannot stop them, HOSC request that ESHT pause the advancement of the proposed changes while HOSC holds a review of them; and

2)    a report on the review be presented to the March committee meeting.