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Poor outcomes for major childhood diseases reflect the low status of children's NHS services
In 2004, the UK government launched the national service framework for children in England.1 It contained a comprehensive set of standards for children's health services and a 10 year timescale for implementation. The framework was welcomed as the first real blueprint for children's health since the Court Report2 almost 30 years before. But with no extra money and no specific targets for health professionals or managers, progress has been slow. Children have been given a low priority, and managers are distracted by high profile government targets for emergency waiting times and surgical waiting lists. There is now real concern and increasing evidence that the National Health Service (NHS) is failing children.
The Healthcare Commission recently produced “Improving services for children in hospital,”3 a review of progress on national service framework standards in England. In 2006, only 4% of trusts were rated excellent and 21% were rated good. While the commission reported considerable progress in improving the hospital environment for children, their review noted a worrying potential for unsafe medical care. Surgeons trained to operate on adults were operating on children, many on only a handful each year. In a small number of NHS trusts too few trained staff were available to provide effective life support for children during the day. One in five trusts were unable to deal effectively with paediatric emergencies at night.
Children in England with diseases such as diabetes and cancer generally do badly, when compared with their peers in the rest of Europe. We have, for example, one of the highest incidences of type 1 diabetes and one of the worst records on diabetic control.4 This could be linked to differences in lifestyle and diet, but poor services are probably at least partly to blame.5 Good diabetic control is vitally important for children because we know that late complications of diabetes in adult life are determined by what happens in childhood. Our inadequate children's services are inevitably storing up problems for the future and we can avoid them only by investing in better care now. Unfortunately, “short termism” has so far prevailed.
The picture is similar for children with cancer. According to recent estimates, children with cancer in Britain have a five year survival rate of 71%, compared with 77% for Scandinavian children and 75% for children elsewhere in Western Europe (France, Germany, Netherlands, and Switzerland).6 British children possibly wait longer for diagnosis and referral to specialists. In Germany, for example, more than 27% of Wilms's tumours are picked up by routine health surveillance by primary care paediatricians.7 This compares with less than 10% in the United Kingdom, where surveillance has been slimmed down, is largely done by nurses, and does not include abdominal palpation at regular intervals. Many office paediatricians in Germany have their own ultrasound machines and are trained to use them.
Our care of newborns also gives cause for concern. The Department of Health has recently reviewed the public services agreement target on health inequalities and infant mortality. The target aims by 2010 to reduce by at least 10% the gap in infant mortality between the socioeconomic class labelled the “routine and manual occupational group” and the English population as a whole.8 The NHS is falling behind in efforts to improve this important indicator of care during the antenatal and perinatal periods, and in the first year of life. England now lies 15th in the European league table for perinatal mortality. Much hope was built around the establishment in 2004 of neonatal networks of care—linked professional groups working across primary, secondary, and tertiary care to ensure equitable and clinically effective services—these have proved hard to establish and coordinate in the real world without adequate national direction and funding.9
All is not lost, however. For example, there have been substantial improvements in community child and adolescent mental health services during the past three years, facilitated by ring fenced additional funding and proxy targets (which serve as indicators that the 10 year plan is on track) for delivering comprehensive services. Recent reports from the Paediatric Surgical Forum,10 the Department of Health,11 and the Royal Colleges12 suggest ways to improve the provision of surgical services for children, and also to improve emergency care and ensure children's safety. A report out this week highlights the difficulties of providing general paediatric surgery in the district general hospital and suggests ways that this might be tackled.13 Networks of well trained staff with appropriate skills and competencies are central to all these efforts.13
Reconfiguration of services is also essential, problems must be resolved with the tariff for specialist paediatric services through “Payment by results” (the system by which providers are paid from a fixed tariff for each individual case treated in NHS hospitals), and true partnerships of care through managed clinical networks (groups of healthcare professionals working across boundaries to provide comprehensive care for particular conditions) need to be established for all major acute and long term childhood illnesses. Above all, children's health must be taken more seriously. It is an investment for the future that we cannot afford to get wrong.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.