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NHS hospitals are making mixed progress on ensuring staff are properly trained and have the specialist skills necessary to provide good quality care for children.

The Healthcare Commission today (Friday) publishes a report detailing progress by 154 NHS acute trusts since it reviewed services for children in hospital in 2005/06.

The 2005/06 review showed that services were generally good when children were inpatients in specialist paediatric services. But there was a need for significant improvement in the care of children being treated in other settings.

This latest report focuses on emergency and day case settings, looking at the areas that the Commission had previously highlighted as particular concerns. Results for each trust across 19 indicators of performance are published alongside the report.

The Commission said that although some trusts had improved, overall progress was mixed.

. Child protection: The Commission found that while more trusts now meet basic guidelines for training staff at least every three years in child protection, there remains significant room for improvement. For example, 71% of trusts now meet guidelines to train anaesthetists, an improvement of 48 percentage points. However, in one in five trusts training of nurses does not meet guidelines and 42% of trusts failed to update consultant surgeons every three years. Looking across all indicators for all trusts, 32% of scores are categorised as “consistently high performing”, 39% of scores are “improved”; 9% “deteriorated” and 20% are “consistently low performing”.

. Managing children’s pain: More trusts are now meeting guidelines to train nursing staff to assess children’s pain and administer pain relief, but again, significant improvement is still required. For example, 65% of trusts now meet guidelines to train emergency care nurses to assess children’s pain, an increase of 12 percentage points. However, almost two-thirds of trusts did not train enough nurses in day case settings to administer pain relief to children, including 14% of trusts that had deteriorated in performance. Looking across all indicators for all trusts, 37% of scores are categorised as “consistently high performing”, 21% of scores are “improved”; 14% “deteriorated” and 27% are “consistently low performing”. These findings are consistent with other reviews, including the Commission’s recent review of organisations providing urgent and emergency care.

. Life support: The Commission said that trusts have made very limited progress in training staff in providing life support to children. Ninety-four per cent of trusts are still failing to provide sufficient training in basic resuscitation and emergency life support to surgeons. Seventy-four per cent of trusts are failing to provide this to emergency care nurses, including 14% that deteriorated. Looking across all indicators for all trusts, 11% of scores are categorised as “consistently high performing”, 15% of scores are “improved”; 11% “deteriorated” and 63% are “consistently low performing”.

. Maintaining skills of surgeons and anaesthetists: The Commission also expressed concern that a high proportion of surgeons and anaesthetists carrying out procedures on children may have insufficient experience of the specific needs of young children. It is recommended that anaesthetists should perform at least 20 consultations with children each year and surgeons should perform at least 100 consultations with children each year, in order to maintain this specialist skill. Seventy-four per cent of trusts performed poorly or had deteriorated when measured against recommendations to maintain the skills of anaesthetists. Sixty-four per cent of trusts performed poorly when measured against recommendations to maintain the skills of surgeons. Looking across all indicators for all trusts, 13% of scores are categorised as “consistently high performing”, 15% of scores are “improved”; 9% “deteriorated” and 63% are “consistently low performing”. However, the watchdog acknowledged that maintaining sufficient experience can be particularly difficult in rural areas where fewer procedures are carried out but there are arguments for doing them as locally and as quickly as possible.

The Commission said the findings do raise questions about the safety and configuration of services that trusts should investigate. However, they do not in themselves provide sufficient information to say whether a particular service is unsafe.

Anna Walker, the Commission’s chief executive, said: “Our follow-up review of children’s hospital services shows there have been improvements but more work is clearly needed. We are particularly concerned about training in child protection. It is absolutely vital that NHS staff working with children know how to recognise signs of child abuse and know what to do if they see it. Experts involved in this review have recommended that training in child protection be increased from every three years, to every year. We agree with this and will be discussing the guidance with the relevant Royal Colleges.

“Another area of concern is that some surgeons and anaesthetists appear to be performing procedures on children without meeting the recommended levels of work to maintain their skills. There may be good reasons for this, but the figures need exploring in greater depth. Hospital trusts, strategic health authorities, Monitor and PCTs all need to review the figures relevant to their services and assure themselves there are no problems.”

She added: "Children are not 'mini adults'. They can't always articulate their symptoms or level of pain and some illnesses that affect children are rarely seen in adults. That's why it is so important that staff are equipped with the skills and training they need to assess and treat children."

The Commission said that some trusts did not meet the recommended level of performance because they had failed to keep adequate records of training. It stressed that keeping proper records was vital to ensuring that trusts know the training needs of staff and can design training programmes to meet those needs.

The Commission has worked with 77 trusts – those failing to meet required thresholds in more than 55% of the indicators - to ensure they produce action plans for improvement. Implementation will be overseen by primary care trusts that commission services, strategic health authorities and Monitor in the case of foundation trusts.



Notes to editors


The Commission assessed both emergency care and day case settings in each trust. It used guidance issued by the Department of Health and by the Royal Colleges to set the recommended level of performance in 19 areas. Trusts were given one of four categories for each area:

. Consistently high performing: Trusts with this score met the recommended level of performance in both reviews.
. Improved: Trusts that did not meet the recommended level in the first review, but did meet it in the follow-up review.
. Deteriorated: These trusts met the recommended level of performance in the initial review, but their performance did not meet the level in the follow-up review.
. Consistently low performing: Trusts that did not meet the recommended level of performance in either review.

Child protection: All staff that work with children should be trained to identify any signs of abuse and to report it through the appropriate channels. Trusts were assessed on whether they met current guidance to train staff in child protection at least every three years.

. Nursing staff in emergency settings: 49% of trusts were “consistently high performing”; 25% “improved”; 10% “deteriorated”; and 11% were “consistently low performing”.
. Nurses in day case settings: 48% of trusts were “consistently high performing”; 31% “improved”; 8% “deteriorated”; and 12% were “consistently low performing”.
. Training of consultant surgeons: 12% of trusts were “consistently high performing”; 44% “improved”; 9% “deteriorated”; and 33% were “consistently low performing”.
. Training of anaesthetists: 17% of trusts were “consistently high performing”; 54% “improved”; 6% “deteriorated”; and 21% were “consistently low performing”.

Managing pain: In both emergency and day case settings, there should be at least one nurse per shift that has been trained to assess and treat children. To ensure there are enough trained nurses to achieve this, trusts need to train 17% of nurses to assess children’s pain and to administer pain relief.

. Nurses in emergency care trained to assess children’s pain: 44% of trusts were “consistently high performing”; 21% “improved”; 9% “deteriorated”; and 16% were “consistently low performing”.
. Nurses in emergency care trained to administer pain relief: 49% of trusts were “consistently high performing”; 19% “improved”; 13% “deteriorated”; and 8% were “consistently low performing”.
. Nurses in day case settings trained to assess children’s pain: 32% of trusts were “consistently high performing”; 21% “improved”; 16% “deteriorated”; and 28% were “consistently low performing”.
. Nurses in day case settings trained to administer pain relief: 14% of trusts were “consistently high performing”; 18% “improved”; 14% “deteriorated”; and 49% were “consistently low performing”.

Life support: Nurses and consultants treating children should be trained in basic resuscitation and emergency life support for children and should have advanced training in paediatric life support every three years. The review set a threshold of 90% of nurses and consultants trained in basic resuscitation within the last year and 17% of nurses and 90% of anaesthetists receiving advanced training in the last three years.

Nurses in emergency care receiving basic training: 7% of trusts were “consistently high performing”; 15% “improved”; 14% “deteriorated”; and 60% were “consistently low performing”.
. Nurses in day case settings received basic training: 22% of trusts were “consistently high performing”; 22% “improved”; 16% “deteriorated”; and 38% were “consistently low performing”.
Consultant surgeons receiving basic training: 0% of trusts were “consistently high performing”; 4% “improved”; 0% “deteriorated”; and 94% were “consistently low performing”.
. Nurses in emergency are with advanced training: 24% of trusts were “consistently high performing”; 14% “improved”; 18% “deteriorated”; and 33% were “consistently low performing”.
. Nurses in day case settings with advanced training: 9% of trusts were “consistently high performing”; 20% “improved”; 13% “deteriorated”; and 54% were “consistently low performing”.
. Consultant anaesthetists with advanced training: 1% of trusts were “consistently high performing”; 8% “improved”; 3% “deteriorated”; and 84% were “consistently low performing”.

Maintaining the skills of staff in surgery and outpatient departments: Planned and emergency operative surgery and anaesthesia for young children needs to be carried out by staff who work with a sufficient number of children each year to maintain their skills. Best practice guidelines recommend that anaesthetists perform more than 20 procedures on children each year in order to maintain their skills. Trusts with any anaesthetists that had carried out fewer than 20 procedures on children did not meet the guidelines. Similarly trusts with more than 18% of surgeons carrying out fewer than 100 operations on children per year were not considered to achieve the recommended level of performance. Also, there should be at least one children’s nurse working within each outpatient department.

. Maintaining skills of anaesthetists: 6% of trusts were “consistently high performing”; 19% “improved”; 6% “deteriorated”; and 68% were “consistently low performing”.
. Maintaining skills of surgeons: 27% of trusts were “consistently high performing”; 8% “improved”; 13% “deteriorated”; and 51% were “consistently low performing”.
. At least one children’s nurse in each outpatient department: 6% of trusts were “consistently high performing”; 16% “improved”; 8% “deteriorated”; and 70% were “consistently low performing”.

* Trusts were scored against 19 indicators. However, two of the indicators relate to more advanced child protection training and involve double-counting with indicators relating to basic child protection training. For this reason, they are not listed above. There will also be a percentage of trusts that did not receive a score because the indicator was not applicable or some data needed to assess the indicator was not available. This means the percentages listed above will not add to 100%.



Information on the Healthcare Commission

The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.


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Megan Tudehope

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