Agenda Item 6.2
25 June 2009
Report of Professor Hugo Mascie-Taylor
Paper prepared by Fiona Campbell: DMM & Jill Asbury: DNM (Acting)
Subject/Title WCHND: Birmingham Hospital Children’s Report
Background papers N/A
Purpose of Paper To provide an overview of the Hospital Review March
Action/Decision required To note any areas of concern that may have
parallels/warning signs for LTHT that require action.
NHS strategies and policy
National Service Framework for Children, Young People
and Maternity Services (2004)
Every Child Matters: Change for Children (2004)
Maternity Matters: Choice Access and Continuity of
Care in a Safe Service (April 2007)
Commissioning Framework for Health and Well Being
Trust’s Strategic Direction
Clinical Governance Framework
Resource impact Work force
Consideration of legal issues N/A
Acronyms and abbreviations
Agenda Item 6.2
The Leeds Teaching Hospitals NHS Trust
25 June Board Meeting
Summary of the Intervention at Birmingham Children’s NHS Trust March 2009
This paper aims to précis the HCC review which published its findings and recommendations following
an investigation into a number of serious concerns that had featured in a report published in the
national press and to note any areas of concern that may have parallels and / or warning signs for
practices at LTHT. This pertains both to current practice and for consideration when planning the
centralisation of services to avoid the experiences that gave rise to the HCC intervention.
Birmingham Children’s Hospital NHS Foundation Trust (BCH) is a specialist children’s hospital
providing a wide range of general and specialist health services to children and adolescents within the
West Midlands and nationally.
The services include liver transplants and specialist paediatric liver diseases, renal transplants,
neurosurgery, craniofacial surgery, cardiac surgery, neonatal surgery and small bowel transplants.
LTHT has all of the above except small bowel transplants.
BCH works with the University Hospital Birmingham NHS Foundation Trust (UBH) to provide certain
specialised services, including interventional radiology, liver transplants, renal transplants,
neurosurgery and craniofacial surgery. In order to provide specialised services, BCH required
consultants from UBH to undertake surgical work at the children’s hospital. Service level agreements
were in place to support this arrangement.
The initial enquiries focussed on the concerns expressed by the clinicians at UBH about the tertiary
The HCC considered:
3.1 Concerns about poor clinical governance arrangements, including lack of incident reporting and
3.2 Allegations about a lack of capacity affecting treatment for patients, due to insufficient planning of
services that included bed capacity, access to theatres and lack of interventional radiology.
3.3 Claims of a lack of clinical leadership at medical & nursing levels.
3.4 Concerns about a lack of action taken by key senior professionals in raising and addressing
3.5 Allegations about a lack of appropriately trained staff particularly in relation to theatres,
arrangements for out of hours cover and the level of support for surgical services by consultants
and junior doctors.
3.6 Concerns about a lack of commonly agreed protocols, policies, procedures, pathways of
admission and criteria for selecting patients for services between BCH and UBH.
3.7 Allegations about a lack of adequate equipment at BCH, including equipment for carrying out
procedures particularly interventional radiology.
Φροµ Χοµµισσιονερσ, χονχερνσ ωερε ραισεδ αβουτ:
3.8 The effectiveness of cross-organisational governance and partnership working between BCH and
3.9 The responsiveness of all relevant organisations and commissioners, once they became aware of
Agenda Item 6.2
4.11Capacity to Deliver Paediatric Services
Increasing demand for surgical services, and continuing challenges, balancing expanding secondary
care services and the demands of tertiary services.
4.12 Access to Beds
Concerns raised about difficulties in admitting patients needing emergency & urgent care due to the
unavailability of beds.
4.13 Access to Theatres
Access to Theatres was a particular problem for urgent but not life threatening cases.
4.14 Access to Interventional Radiology
Lack of access to interventional radiology leading to delays in treatment and / or transfer out to other
hospitals, and to ‘open’ procedures being undertaken where interventional radiology may have been
Increasing demand for interventional radiology.
4.15 Theatre Staff
Difficulties in theatre staff maintaining competence when small numbers of operations take place per
year, a particular problem in neurosurgery and other highly specialised clinical specialities.
Poor availability of equipment for specialised cases both in theatres and interventional radiology.
Reports of Consultants from UBH bringing equipment with them.
4.17 Staff Rotas and Arrangements for Out of Hours Cover
A lack of confidence from some speciality consultants in the introduction of the Hospital at Night
Poor clinical leadership at ward level (particularly in relation to Neurosurgery), led to poor
communication between medical and nursing staff, strained relationships and poor morale.
Consultants on honorary contracts unclear about the governance structures they were to follow,
leading to concerns being raised verbally and informally rather than using a clear incident reporting
4.2 Partnership Working
No culture of sharing information between BCH & UBH, miscommunication about the location of
Paediatric services distracting from the actual concerns of the UBH consultants.
No shared actions following the concerns expressed about the tertiary services.
The involvement of the UBH consultants had to be about more than contributing technical services.
There was no evidence of any serious incidents causing harm to patients, although there was
evidence of less than optimal care being provided to some patients at BCH.
There were many serious concerns expressed by some of UHB’s and BCH’s consultants who were
responsible for providing paediatric tertiary services at BCH.
The concerns related in large part to difficulties in access to beds and theatres, theatre staff not having
the required skills to assist in certain specialist procedures, and the arrangements that were in place
between BCH and UHB.
Agenda Item 6.2
However, the concerns had not always been formally raised through BCH’s established systems, nor
had they always been effectively managed in a timely fashion.
BCH had struggled to ensure that it had sufficient capacity to meet the increased demand for its
services, due to a steady rise in referrals from general hospitals, and this had resulted in delays, less
than optimum standards of care, and in patients needing to be redirected to other providers. The Trust
had not, in the past, responded to this increased demand with sufficient urgency, nor were there
effective systems to monitor what happened to those patients who were unable to receive services
from the Trust due to lack of capacity.
6.0 Summary of Recommendations from HCC Report – LTHT Position in Italics
BCH, with relevant commissioners, needs to ensure that it actively monitors the demand and capacity
for children’s services, including information about those patients it has not been able to admit.
LTHT is underway with this work in most areas but needs to strengthen data collected to capturing
100% of refused admissions and reasons why.
The DMM & DNM will work with the Paediatric In-patient placement team, the PICU teams and the
Neonatal Units to ensure that we effectively capture this information to assist the future planning of
BCH needs to review its strategies and policies to improve its management of admissions and beds,
and ensure that staff throughout the Trust keep to these. It also needs to work with its consultants to
ensure that patients needing urgent care are admitted in a timely manner.
The model used in LTHT is via the Paediatric In-Patient Placement Team which delivers patient flows
successfully the majority of the time. There is still work required to address concerns that have been
raised about access to Neonatal Surgical Beds. The he introduction of the Neonatal Nurse further
work to manage discharge is ongoing. The Divisional Management team will keep this under review.
BCH and commissioners of paediatric tertiary services must continue to work actively to manage the
demand and provision of paediatric services at the Trust.
LTHT does this with help of clinicians and the local specialist commissioning (SOAPS) group and the
Specialist Commissioning Group (SCG). Future plans are discussed and evidenced within Schedule 2
of the LTHT Business planning processes.
LTHT is currently planning services for the next 5 years using projected birth rate information (see
BCH needs to review the way it organises capacity and prioritises cases within theatres, to ensure that
patients requiring urgent and emergency surgery gain access to theatres in a timely manner.
This is the area that whilst significant amounts of work have been undertaken, there are still concerns
about inadequate provision raised by clinicians. Children’s centralisation (CSR) provides an
opportunity to review the current model and increase the provision of acute theatre capacity for
The Divisions are working closely together and with clinicians to resolve this.
BCH needs to urgently agree a clear plan to ensure that it has the capacity and systems in place to
provide sufficient and timely access to elective and emergency/out-of-hours interventional radiology.
Agenda Item 6.2
This is an area that works sufficiently now but requires further planning to ensure that this remains the
case post centralisation of Children’s services. This is currently being addressed in the Radiology
Primary Planning Group which was established to support the planning of the various centralisation
plans on all radiology service, with particular reference to the Liver Transplant Programme.
Interventional Radiology and the involvement of anaesthetic staff needs clear plans to ensure a robust
service post centralisation. The work is ongoing and may require investment and will be subject to
scrutiny as part of the challenge processes with the CSR programme.
BCH must ensure that it provides, for urgent renal transplants and Neurosurgery, an appropriate and
sustainable level of support is available within theatres at all times. This needs to be informed by
discussions with the surgeons involved about the standards of support required from theatre staff.
For LTHT Paediatric patients this has not been flagged as a problem within the current service. The
CSR primary planning group for this area is in the process of detailing the work to ensure capacity
remains sufficient for existing LGI specialities and is taking into account increasing birth rates when
planning the transfer of services from SJH.
There should be clarity between BCH, UHB and UHB consultants regarding what the UHB consultants
will provide in terms of the specialist paediatric service, and what standard of support and equipment
these consultants need in order to enable them to provide that service.
There have been no serious concerns raised within current services. For CSR, this is being
addressed within the Primary Planning Groups to ensure that the correct equipment is available and in
sufficient quantities to ensure safe delivery of planned and acute services post centralisation. Of
relevance to this point are the ongoing discussions about the placement of the robot currently in use
at SJH and its place post centralisation.
When there are equipment delays currently these are escalated through the formal reporting systems
and feedback through the governance / audit meetings.
BCH needs to review urgently the arrangements for Hospital at Night with senior clinical staff, to
ensure that any outstanding concerns have been properly addressed.
Hospital at Night is being looked at currently to see if it is feasible in some of the clinical areas with no
clear plan developed as yet .Medical, and nursing and HR representatives are on the feasibility group
which are expected to make recommendations about this in the future.
BCH must agree, together with relevant consultants and its commissioners, a clear plan setting out
actions being taken to ensure that craniofacial patients will be treated at the appropriate age and that
any delays will be minimised.
There have been concerns in previous years about access to PICU beds for Craniofacial patients,
however the PICU team have actively worked with the teams involved in craniofacial work and this
has not been identified as a problem in recent years.
It is recognised that, when planning centralisation theatre capacity is a crucial element in preventing a
return to previous problems with this and other patient cohorts. Clinicians are working with the
planning teams and theatre managers to plan and map theatre requirements within the centralisation
plan, and will be monitored through the Divisional Challenge process.
Agenda Item 6.2
BCH must develop better, formal, communication with UHB consultants undertaking work at the Trust,
to ensure that any concerns are identified and addressed in a timely manner, and that the views of
these consultants are formally incorporated into BCH’s arrangements for governance.
As a single Trust the emphasis needs to be on all clinicians using the formal mechanisms that are
known to all when reporting concerns / incidents, and not to resort to informal discussions with their
colleagues in Paediatrics. All staff have a responsibility to use and refer concerned staff to the formally
recognised systems, this needs emphasising to all clinicians.
This also applies to the outreach clinics in which LTHT staff work or have staff working in LTHT but
employed by NHS Leeds for instance in Community Paediatrics. LTHT have been clear that the
Governance responsibility lies with the organisation that holds the patient details on their PAS
systems, and that the clinicians must familiarise them selves with local reporting structures.
Job plans that take account of the time spent by UHB consultants at BCH need to be developed by
UHB. BCH needs to clarify and agree with UHB the level of input it requires from UHB staff, including
time to enable more involvement of consultants in the clinical governance and management structures
at BCH. Once the job plans are developed, BCH should be involved in the appraisals and professional
development of these consultants.
LTHT job planning is about to be re-launched with a focus on transparency, efficiency and
When centralising services the Paediatric planning team need to be mindful of the BCH experience
and be clear about the contribution of visiting (adult / paediatric mix) consultants to ensure their role
contains more than the delivery of technical skills. The DMM’s and CD’s will need to provide this
clarity in the relevant job plans.
BCH and UHB, with the support of the commissioners, must agree on and implement a model of care
delivering high-quality paediatric services, in line with the requirements of Monitor, the independent
regulator of foundation Trust’s.
Monitor must ensure that both Trust’s play their part in implementing this new model of care.
This does not apply currently to LTHT as we do not hold FT status, however in the planning,
commissioning and delivery of services the aim should be to deliver our Paediatric Service to Monitors
6.0 Summary of Relevance to LTHT Services
The senior management team are requested to note the findings of the HCC Summary of the
Intervention at Birmingham Children’s Hospital NHS Foundation Trust. Senior Management Team are
asked to recognise that whilst LTHT has a similar range of services , the distinct advantage that LTHT
has over BCH is that all the services are provided by the one organisation. However, the experiences
at BCH are a lesson for LTHT to consider and use as a gauge when planning the centralisation of
services at the LGI site.
Within existing and future services there are similar issues services where small numbers of highly
specialist clinical services are delivered. All the teams involved are planning to ensure competence
amongst teams is maintained, this is being addressed through the Primary Planning Groups and will
be monitored through the Divisional Challenge process.