Wednesday, 5 September 2012

'We're doing medicine in a really inefficient way,' says RCPCH leader

'We're doing medicine in a really inefficient way,' says RCPCH leader: Dr Hilary Cass, president of the Royal College of Paediatrics and Child Health, explains her vision for the future and why she thinks 'defocusing on hospitals' would improve care.

"It is unusually emotionally demanding work," says Dr Hilary Cass of her role as a consultant in paediatric disability at St Thomas' hospital in central London. Some of the children she works with have profound disability. Her caseload includes dealing with the patients' and their families' hopes and hunger for information about their child's treatment and chances. Palliative care is also part of Cass's workload.
"Sometimes it's about parents making decisions about when they want to carry on pulling out all the stops, by having maximum intervention, and when they want to be less interventionist and say 'quality [of life] is now more important than quantity' for their kid," she explains.
Advising parents who are exploring what they hope will be a miracle cure for their child is not easy either. "It may be that parents are searching and searching and searching for a cure. They're spending a lot of time on the internet. You have to manage their expectations and try to help them understand the limits of what's possible and what's not possible."
Fulfilment comes from the positive feedback that even bereaved parents can give. "Actually, if a family can walk out of the hospital having lost their child and say that they couldn't have been better supported, then I can go home and feel OK about that," says Cass.
After 30 years as a doctor, she has recently taken over as president of the Royal College of Paediatrics and Child Health (RCPCH), which represents the UK's 11,500 children's doctors. Heads of medical royal colleges tend to be either innovative leaders who challenge their members, or those who opt for an easier life and ask their colleagues few uncomfortable questions about the care they provide. The NHS's daunting in-tray, which includes a tight financial squeeze, reforms-induced upheaval and the imperative to treat more patients outside of hospitals, means there is more demand for the former.
Fortunately Cass is one of those. Too much paediatric care is not good enough, she states firmly. The UK's mortality rate for under-16s is the highest in western Europe, 26% of child deaths are potentially preventable and child mortality from conditions that are treatable is much higher here than in other European countries. These sobering facts could be taken as underlining her point. Can she explain such findings?
"It's going to be a combination of systems, people and education, both of the public as well as the profession," replies Cass. The RCPCH has recently launched an inquiry, called Child Health Reviews – UK, to find out why too many children are dying unnecessarily every year and to then take remedial action.
Without prejudging its conclusions, Cass offers a few initial thoughts. Research by the Confidential Enquiry Into Maternal and Child Health in 2008, called Why Children Die, also concluded that inadequate training was a significant factor in at least some of these deaths, she notes. So the college is scrutinising that issue closely.
Cass explains that the current configuration of paediatric units also helps explain inadequacies in the care of some children with more common, less serious conditions, such as asthma. There are 218 inpatient units specialising in children's health across the UK, though the college believes there should be far fewer.
"The recent Safe and Sustainable review of children's heart surgery services is just one specialist outcome of a broader problem, which is that we cannot sustain services safely on the 218 inpatient units. That's too many and it's spread too thin, and therefore you are not getting the quality of care in every one of those units that we would like children to be receiving," she says. "We're doing medicine in a really inefficient way that's not cost-effective. This isn't just [about] children with rare heart disease. It's about children with asthma, diabetes, pneumonia, meningitis – common conditions that we are running inadequate staffing levels to look after properly."
A shortage of middle-grade doctors or registrars also means some of the 3,000 paediatric consultants are having to fill gaps in rotas. "That can be done in a planned way or, more worryingly, they end up having to be on call at short notice because there isn't anyone on that night and then they have to work the next day. That's where it becomes risky. You wouldn't want to be on a plane being flown by somebody who's been up the night before and is still working the next day, so why would you want your kid looked after by somebody who is sleep-deprived, who thinks they are OK but are not at their lowest possible risk level?" she asks.
The solution to too many units, staffing problems and inconsistent care is either to reduce units by 25% or increase the number of consultants by 50%, she says. Although she adds: "I recognise that the first one is politically difficult and the second one is financially difficult."
According to Cass, the NHS needs to "defocus on hospitals as the happening place to be" and start delivering many more services much closer to patients' homes. She views the tariff system of payment for hospitals' activity as "incentivising people to come to hospital like bees to honey" and "a completely surreal system". A key part of the answer, Cass suggests, is a huge change in how and where many paediatricians work.
She wants to see a big expansion in the handful of community paediatricians and the latter working in or with GPs' surgeries. Children form 25% of family doctors' workload. Having paediatricians working in close collaboration with them, and also with nvenient for patients, cheaper and produce better care. Her own trust is trying to arrange a pilot along these lines.
If such new premises existed, she adds, "you could have teenage drop-in clinics, health promotion and healthy eating advice all done from there, as well as the management of long-term illness." This is part of the emerging new orthodoxy in the NHS – hospitals bad, community good – but a tough message from a hospital doctor to a membership who may not all rush to embrace her vision of the future of the profession. The Guardian

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