A critical phase for children’s health

Children's health is an emotive issue, so the question of how best to improve health services for the nation's children is a knotty problem. It is also one which some of the best brains in the NHS are currently tackling, and is viewed as the key to improving the country's poor showing in international league tables in the years to come.

One suggestion is to streamline all Scotland’s various health services for children into one service – a separate Children’s NHS with its own identity and team spirit caring for the young from Lerwick to Lanark.

It is a piece of blue-sky thinking which emanated from Professor George Youngson, a member of the think tank the Child Health Support Group, set up under ex- health minister Malcolm Chisholm.

At first glance, it is a radical and impractical suggestion. But at a closer look, there is certainly a case for major change.

A damning report in the Financial Times recently showed that questions are beginning to be asked about the Scottish Executive and the National Health Service’s ability to manage effectively the huge level of investment now going into health in Scotland. Very large sums are now being spent, more than in almost anywhere else in the world – pounds-1600 per person per year, significantly more than in England.

But as yet there is little evidence that the service is improving. A recent report by Audit Scotland said there were “concerns about the robustness of financial planning at both national and local levels”.

The push is on to ensure that this spending leaves a legacy which will continue to be felt for generations to come – rather than being poured into keeping an antiquated system ticking over.

Youngson’s suggestion emanates from the understanding he has, as an Aberdeenbased paediatric surgeon and member of the CHSG, of some of the specific problems facing Scotland. He says current administrative practices may be out of date and insensitive to the needs of children.

Scotland has a comparatively small population spread across a large geographic area, and the patient population dealt with by paediatric services is by international standards tiny, at less than one million.

As medicine becomes increasingly specialised that means Scotland has a very small number of highly-trained and extremely important paediatric specialists, who tend to be based in the central belt. But their patients are scattered across 15 health boards with 15 ways of working and 15 sets of policies for treating their problems.

Other changes such as the new regulations about the hours junior doctors can work and about the training they must receive, mean that consultants’ time is more valuable than ever and they are, through necessity, looking to support each other and work more as a team across Scotland.

All of this puts a strain on children’s health services in Scotland, and one suggestion is the creation of a “superhospital” for treating young people But Professor Youngson says the case for this is unconvincing: “This model fails to accommodate children in their locality and runs the risk of placing all eggs in one basket. It also fails to make maximum use
of existing resources in each region of Scotland.”

Such centralisation is already the case for certain acute services. The expertise is in the major cities and outreach teams travel to rural areas to treat children in need there. That means the health authority in the major cities effectively bears the cost of treating those children, another anomaly.

Some medical problems – like heart operations for children – are nationally organised so that a child anywhere will be taken to Yorkhill or Edinburgh’s Hospital for Sick Children and their care will be managed by that hospital.

Another problem – cleft palate – is “networked”, meaning that a care plan has been drawn up on a national basis and every health authority in Scotland manages it in the same way.

Youngson’s suggestion is effectively that all children’s services be networked into their own service. He says: “It would change the emphasis away from improving the centres of excellence (which may still happen) to strengthening the weakest links and introducing consistency of care for all parts of Scotland.”

Such a service would closely monitor and assess care for all parts of Scotland. Health authorities even in remote areas like the Highlands and Islands would be able to draw more on the increasingly abstruse, particular knowledge of specialist doctors.

Within one child health service, auditing and management could be streamlined and Youngson also believes it would be easier to build links with the community health partnerships responsible for first-level care, health visitors, antenatal care and GPs. One of the specific problems facing children’s medicine is the number of links to other services such as education and social work.

One of the key elements of the children’s NHS suggestion is that people working within the children’s health service would have a clear “corporate identity” – making communication easier, Youngson suggests The concept is broadly supported by the charity Children in Scotland, which argues that the Executive needs to put children’s health higher up the agenda. The charity has called for child health to be made one of the 12 national NHS
priorities – currently it is not.

Bronwen Cohen, chief executive of Children in Scotland, said: “Children’s health impacts on all areas of their lives, how they learn, grow and develop into adults. Improving children’s health will improve the nation’s health today and in the future. We remain concerned that child health is not one of NHS Scotland’s 12 stated priorities.”

A unified health service for children might make sense, she said: “Health professionals are having to work more closely with professionals from education and social work, as well as the voluntary sector. Working together effectively across sectors is made more difficult if
different sectors do not share the same priorities.”

However the suggestion has not met with compete approval so far. Professor David Kerr is chairing the executive’s National Framework for Service Change which has a sub-group specifically looking at acute care for children.

While he acknowledges there may be a case for reorganisation in order to give children’s health needs greater priority, he adds: “I cannot see that the idea of a separate children’s NHS has much to recommend it at this time.”

Danny Crawford of Greater Glasgow Health Council was also underwhelmed. He argues that while there are significant problems relating to children and health in the Glasgow area, they do not lie with the high-profile acute care services situated at Yorkhill which he said were “as good as you can get anywhere in the UK, maybe in the world”. Instead, his concern is over issues that tend to grab fewer headlines, like help for autistic children and speech therapy where there are long waiting lists.

Pointing out that most health treatment for children takes place on a primary level at health centres and GP surgeries or in the community, he said a children’s NHS would not necessarily improve them.

ProfessorYoungson himself is conscious of the danger that instead of an inclusive, broadly-sited national service meeting the needs of children, the plan could lead to problems such as creating a parallel layer, with unnecessary replication.

“There is also a danger that local health boards could distance themselves from the national service and lose interest in local perspectives and local needs. It needs to be properly thought through, ” he said.

Professor Kerr’s team and the CHSG will continue doing just that. As the recent campaigns over hospital closures made clear, there are huge barriers to change in Scotland. At the same time, it is also clear that there is plenty of room for improvement.

The Scottish Sunday Herald
January 25th 2005