Reconfiguring paediatric services

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The reconfiguration of clinical services report provides new insights into the drivers of reconfiguration and the underpinning evidence. It builds on a major analysis, commissioned by the National Institute for Health Research (NIHR), of reviews of service reconfigurations conducted by the National Clinical Advisory Team (NCAT).

This page summarises the report's findings on the reconfiguration of paediatric services.

Proposals reviewed by NCAT

  • Centralising paediatric inpatient units
  • Retaining, creating or closing stand-alone paediatric assessment units (PAUs)

Key drivers of paediatric service reconfiguration

Workforce, cost and safety were the primary drivers of this type of reconfiguration.

Context and relevant policy

  • The rate of admission for children under 15 grew by over 25 per cent between 1999 and 2010 (from 63 per 1,000 to 81 per 1,000) and the average length of stay has fallen from 3.8 days in 1996/7 to 1.9 days in 2006/7, with 71 per cent of admissions lasting less than a day. The consequence has been a significant reduction in the number of paediatric beds.
  • Getting the right start: National Service Framework for children – standard for hospital services was the most recent national policy statement on children’s hospital services.
  • Specialist paediatric services, including paediatric intensive care, are now commissioned by NHS England, which has developed a range of service specifications for different sub-specialist areas.
  • Centralisation of paediatric services has been on the agenda for almost 20 years, driven by trends in paediatric activity and a desire to maintain trainees’ exposure to less common childhood diseases.

The current evidence base

Paediatric inpatient units need to be staffed by paediatric consultants and the appropriate level of specialist paediatric nursing. There is little evidence, outside of professional consensus, to guide the appropriate level of medical staffing – in particular the balance between senior and junior doctors, and medical versus specialist nursing staff.

There is little research to guide an optimal configuration of paediatric services.

Constraints on the paediatric workforce are key drivers of future configuration, with more evidence needed about safe staffing models for ambulatory services. The limited evidence available suggests there is scope for paediatric services to shift further towards a primary/community care-based model.

Relevant college guidance

Paediatric inpatient unit medical staffing (Royal College of Paediatrics and Child Health 2011)

  • Every child or young person who is admitted to a paediatric department with an acute medical problem is seen by a paediatrician on the middle grade or consultant rota within four hours of admission.
  • Every child or young person who is admitted to a paediatric department with an acute medical problem is seen by a consultant paediatrician (or equivalent staff, speciality and associate specialist grade doctor who is trained and assessed as competent in acute paediatric care) within the first 24 hours.
  • At least one medical handover in every 24 hours is led by a paediatric consultant (or equivalent).
  • A paediatric consultant (or equivalent) is present in the hospital during times of peak activity.
  • All general acute paediatric rotas are made up of at least ten WTEs, all of whom are EWTD compliant.

Paediatric inpatient unit nurse staffing (Royal College of Paediatrics and Child Health 2008)

  • A minimum of two registered children’s nurses must be in the inpatient unit at all times.

Paediatric assessment units

  • Consultants, or someone assessed as competent to work on the paediatric consultant rota, should be ‘available’ to a stand-alone paediatric assessment unit but this may not involve consultants being present; their opinion can be reached via phone (Royal College of Paediatrics and Child Health 2014).
  • Wherever the consultants are based, children staying for more than eight hours at a PAU should receive a consultant review of their case before further treatment decisions are made (Royal College of Paediatrics and Child Health 2011).
  • ANPs can lead care for children in stand-alone PAUs, with remote consultant support using co-located A&E middle-grade doctors to provide emergency medical assistance when required (Royal College of Paediatrics and Child Health 2009).
  • PAUs should be staffed by at least two children’s nurses at all times (Royal College of Nursing 2013a).
  • The RCPCH has recommended the closure of smaller paediatric inpatient units, to be replaced by PAUs, in order to resolve workforce pressures (Royal College of Paediatrics and Child Health 2013a).