Carol Ewing

Enhancing parents' confidence to care in acute childhood illness: triangulation of findings from a mixed methods study of Community Children's Nursing.

BACKGROUND Childrens emergency hospital use is of concern internationally, but there has been little examination of home care by nurses. AIMS To examine the care provided by community childrens nurses during acute illness. DESIGN Triangulation of findings from case studies of three Community Childrens Nursing Teams. METHODS Parents or carers (n = 763) completed questionnaires between 2008-2010 about their contacts with nurses and satisfaction with aspects and overall assessment of nursing care provided. Eighty-one individuals participated in semi-structured interviews: 29 parents/carers described their experiences and explained their questionnaire responses in more detail; 13 children talked about their care both in hospital and at home; and 39 nurses and other healthcare providers explained how nurses supported care of children at home. Questionnaire data were analysed descriptively and interview data qualitatively. The findings were integrated by triangulation of methods (questionnaires and interviews) and of data from different informants (children, parents, healthcare providers). RESULTS Nursing care most frequently took the form of advice and education by either home visits or telephone contact. Parents and children were reassured by access to nurses and it gave them confidence to care at home. Most respondents thought that it reduced the time their children spent in hospital. CONCLUSIONS Nurses can make an important contribution to supporting parents to care confidently for their children at home to reduce or even to avoid hospitalization for acute conditions and give them confidence to manage future episodes of illness.

Making sense of strategic clinical networks

Maternity and childrens services are one of the four service areas for which Strategic Clinical Networks1 (SCN) have been designated in England. Is this latest introduction to the new commissioning framework good news or something that will hardly impinge on the working lives of most paediatricians? More importantly, will this impact on the health outcomes for babies, children and young people (CYP)? Certainly there is much room for improvement; across the UK there remains huge variation in both health and service quality for children.2–4 Furthermore, a review of health services across Western Europe has recorded that the UK has moved from the average to the worst for ‘all-cause’ mortality rate for children aged 0–14 years. There are many reasons for this statistic, but the authors concluded that some health systems are not keeping up with the changing health needs of children, and that a whole-system approach is required to improve outcomes.5 Consequently, if SCNs provide an opportunity to make the necessary cross-organisational changes to service, then it is beholden on paediatricians to engage. NHS Englands (NHS-E) statement of its intentions to host and support SCNs started by observing1 that: “Clinical networks are an NHS success story…networks perform varied and valuable roles…” A recently published book,6 which assesses the development of managed clinical networks to date, concludes that while the record is perhaps rather more mixed, nevertheless, clinical networks “should be given more time to develop and reach their potential”. Networks can make effective use of scarce resources, bridge the cracks between services offered by ‘self-interested’ NHS organisations, and move knowledge around clinical communities more effectively than hierarchy and the market. 1996 was a key year for the idea of networks. A review7 argued that there have always been networks in the NHS but ‘ad hoc’ …

The changing UK paediatric consultant workforce: report from the Royal College of Paediatrics and Child Health

Objectives To determine if there had been changes in the size of the UK paediatric workforce and working patterns between 1999 and 2013. Design Analysis of prospectively collected datasets. Setting UK consultant paediatricians. Interventions Data from the Royal College of Paediatrics and Child Healths workforce census from 1999 to 2013 and the annual surveys of new paediatric Certificate of Completion of Training (CCT) and Certificate of Equivalence of Specialist Registration (CESR) holders between 2010 and 2013. Main outcome measures Paediatric consultant numbers, programmed activities (PAs) and resident shift working. Results The UK paediatric consultant workforce grew from 1933 in 1999 to 3718 in 2013. Over the same time period, there was a decline in the number of consultants with a primary academic contract from 210 to 143. There was an increase in the proportion of consultants who were female (40% in 1999 to 50% in 2013, p<0.01). The median number of PAs declined from 11 in 2009 to 10 in 2013 (p<0.001) as did the median number of PAs for supporting professional activities (2.5–2.3, p<0.001). In 2013, 38% of new consultants in general paediatrics or neonatology were working resident shifts. Between 2009 and 2013, the proportion of less than full-time working consultants rose from 18% to 22%, which was more common among female consultants (35% vs 9%). Conclusion The paediatric consultant workforce has doubled since 1999, but more are working less than full time. The decline in those with a primary academic contract is of concern.

Career intentions and choices of paediatricians entering training in the UK

Introduction The paediatric workforce has grown substantially in recent years. Roles have changed considerably with the introduction of working time legislation and a move towards a trained doctor solution. By gaining a better understanding of paediatric trainees’ career intentions, this study aims to assess whether the right workforce is being trained to meet the future demand for paediatric services in the UK. Method A survey was sent to paediatric specialist trainees, when they were expected to have completed their 1st year of Specialty Training or Fixed Term Specialty Training Appointments, in 2009 (part 1). A second survey was sent to the same cohort when they were expected to have completed their 3rd year in 2011 (part 2). Results In part 1 of the survey, the response rate was 79.1%. In part 2 the response rate was 80.5%. Of those who had responded to part 1, 87.4% also responded to part 2. The attrition rate of trainees leaving the paediatric training scheme between the 1st year and 3rd year of training was 15%. Of those still training in paediatrics after the 3rd year, 38.7% intended to be subspecialty paediatricians, 25.7% general paediatricians, 5.4% community paediatricians and 3.5% academic paediatricians. 26% were undecided and 0.6% did not intend to follow a career in paediatrics at all. The proportion of trainees who were undecided about their career intentions had risen substantially from 7.7% after the 1st year. There was a decrease in trainees’ confidence in obtaining a consultant post between the 1st year and the 3rd year. Conclusions Workforce planning is a complex task and this study shows that trainees will change their career plans while progressing through their run-through programmes. A better understanding of these factors will enable the Royal College of Paediatrics and Chld Health to deliver the right workforce for the UK.

Substituting community children's nursing services for inpatient care: a case study of costs and effects

Objective To compare childrens pathways to and through Community Childrens Nursing Team (CCNT) care, and NHS costs, before and after relocation of inpatient services and extension of a paediatric Emergency Department and Observation and Assessment Unit (ED/OAU). Design Case study. Routinely collected data on activity and staffing were provided by the CCNT. Parents completed questionnaires about their childs use of healthcare services and satisfaction with care preservice reconfiguration (n=221) or postreconfiguration (n=210). The cost of service use was compared prereconfiguration and postreconfiguration. Patients Children referred to CCNT care. Main outcome measures Healthcare service use and associated costs, satisfaction with CCNT care. Results The mean number of services used before referral to the CCNT reduced from 2.8 to 1.6, and the proportion using only one service increased from 26% (n=58) to 61% (n=128). Inpatient admission during CCNT care reduced from 6% (n=13) to 2% (n=4), and ED attendance from 37% (n=79) to 16% (n=31). There was a considerable fall (25%) in the cost of CCNT care, and a sharp fall (55%) in the average overall NHS cost of care. CCNT care was rated ‘excellent’ or ‘very good’ by 85% of respondents both prereconfiguration and postreconfiguration. Conclusions A CCNT provided an alternative to hospitalisation when acute general paediatric services were reconfigured to substitute for a relocated hospital. Childrens pathways to CCNT care were shortened. The average cost of CCNT care and overall NHS cost were lower following reconfiguration. Satisfaction remained high throughout.

Allergy testing in predicting outcome of open food challenge to peanut

FIG 1. Receiver operating characteristic curve illustrating sensitivity and specificity of peanut SPT, peanut specific IgE, and peanut components in relation to open oral peanut challenge. To the Editor: We read with interest the report by van Erp et al showing that in 81 Swedish children with suspected peanut allergy, 0.1 and 5.0 kUA/L Ara h2 cutoff values correctly predicted the outcome in 62% of children undergoing peanut double-blind placebocontrolled food challenge, and with the addition of basophil activation test Ara h 2 and 6 80% were correctly predicted. They proposed a flowchart for the diagnosis of peanut allergy. Clinicians managing peanut and other food allergies need diagnostic tools that are accurate, but also simple and readily available. Complex algorithms involving artificial specific IgE cutoffs and labor-intensive basophil activation test assays with restricted availability are not a practical option. We retrospectively surveyed the value of peanut skin prick, peanut IgE, and component allergy tests (Ara h 1, 2, 3, 8, 9) in predicting the outcome of 130 open peanut oral food challenges (OFCs) in children aged 1 to 18 years (median, 7 years) attending our specialist pediatric allergy center between 2012 and 2016. OFC was performed in children who had not reacted to peanuts since early childhood, where there was no history of direct ingestion of peanuts, or when the family members were too anxious to try the food. Written consent and approval was obtained from all patients. IgE concentrations were measured by automated Immuno-CAP250 processor (Thermo Fischer Scientific, Loughborough, United Kingdom). Sensitization was defined as peanut, or peanut component IgE level of 0.4 kUA/L or more, or a skin prick test (SPT) wheal size of 3 mm or more. Oral challenge with peanut butter (in children <6 years old) or shelled peanuts was performed using a standardized open-challenge protocol, increasing the amount of peanut every 15 minutes (25 mg, 100 mg, 200 mg, 1 g, 5 g, 20 g). A positive challenge was defined as objective signs of allergy (urticaria, angioedema, vomiting, wheeze). Eighty-eight (68%) passed their OFC. Twenty-four percent failed at 25 mg, 34% at stages 100 to 1000 mg, and 42% reacted to 5 g or more of peanuts. Only 1 patient suffered anaphylaxis (wheeze), requiring intramuscular epinephrine. Ara h 2 above our laboratory’s threshold of 0.4 kUA/L or more correctly identified 95% of children, with a positive predictive value of 94% and a negative predictive value of 97%. This was significantly higher than SPTs’ wheal size of 3 mm or more (positive, 75%; negative, 76%) and peanut allergen specific IgE level of 0.4 kUA/L or more (positive, 81%; negative, 84%) (Fig 1). A 2-year-old and a 5-year-old child had a negative Ara h 2 but failed the OFC, both reacting (vomiting and urticaria) after consuming 5 g or more of peanut. Although the diagnostic accuracy of OFC surrogates is likely to vary by region, and, for instance, in Mediterranean areas, Ara h 2 may have a lower predictive value, our study demonstrates that in the North West of England an Ara h2 peanut component above baseline (>_0.4 kUA/L) predicts the outcome of peanut OFC significantly better than either peanut SPT or peanut specific IgE. On the basis of our data and that of other studies, we suggest that peanut SPT and peanut specific IgE be replaced by Ara h 2 as the routine screening test for peanut allergy. Shelly Rajput, MB BS Vibha Sharma, MD Stephen M. Hughes, MD, PhD Carol I. Ewing, MD Peter D. Arkwright, MD, PhD From the University of Manchester and the Department of Paediatric Allergy & Immunology, Royal Manchester Children’s Hospital, Manchester, United Kingdom. E-mail: peter.arkwright@nhs.net. This study was funded by the University of Manchester. Disclosure of potential conflict of interest: V. Sharma serves on the board for Mead Johnson and Nutricia; receives grant support from the North West Paediatric Allergy network fund; and receives travel support from Alk-Abello, Allergy Therapeutics, MEDA, Mead Johnson, and Nutricia. C. I. Ewing serves as a consultant for NHS Trust Development Authority, England. P. D. Arkwright receives travel support from Allergy Therapeutics and Nutricia. The rest of the authors declare that they have no relevant conflicts of interest.

Measuring and improving the quality of NHS care for children and young people

Children and young people (CYP) in the UK suffer worse health and well-being outcomes than their peers in comparable countries across a range of physical and mental health measures, including overall mortality and deaths from long-term conditions such as epilepsy, asthma and diabetes.1–6 While social determinants, in particular relatively high rates of child poverty, account for some of this mortality gap, there is growing evidence that many deaths could be prevented through more accessible and higher quality National Health Service (NHS) care.2 3 In addition, evidence suggests that the NHS care typically results in worse patient experience for young people aged 16–24 than older adults,7 and that there is sometimes objectively lower quality care for CYP than for adults. The UK ranked fourth out of 30 countries in a recent comparison of the quality of adult diabetes care, whereas the quality and outcomes of diabetes for patients aged 0–24 years lag well behind that of comparable countries.8 9 In addition to moral, public health and economic arguments for improving care quality for CYP, the UK also has legal obligations under the United Nations Convention on the Rights of the Child to provide the best healthcare possible (article 24) and to involve CYP in decisions that affect them (article 12).10–12 Validated and appropriate quality measures are necessary (but not sufficient) to improve care quality and health and well-being outcomes.13 CYP have historically been under-represented in many quality frameworks; for example, one 2015 study reported that 0/77 indicators in the Quality Outcomes Framework for primary care were applicable to CYP.14 Following the recommendations of the CYP Health Outcomes Forum,15 the number of indicators in the NHS Outcomes Framework has increased,16 and the perspectives of CYP using NHS services have been given greater weight …

Comparison of the costs of care during acute illness by two community children's nursing teams

Objective To compare the costs associated with care by two community childrens nursing teams (CCNT). Design A case study incorporating questionnaire survey, analysis of routinely collected data and analysis of costs in the north-west England. Patients Children with acute illness referred for CCNT care. Interventions Two CCNT provided care for 273 children during acute illness in order to reduce the number and duration of hospital admissions. Main Outcome Measures Costs of CCNT, other services and costs to families. Results The objectives of both CCNT included shortening and avoiding hospitalisations. Most (45 (58%) in case A and 150 (77%) in case B) children were referred for infections. There were differences in the proportion of children who had been hospitalised (45 (57.7%) and 78 (40%)), the mean number of services used before referral to CCNT (1.6 and 2.2) and the staffing profile of the CCNT. There was a statistically significant difference in the overall mean cost to the NHS of CCNT care (£146 and £238, 95% CI for difference of means 7 to 184), associated with higher proportions of children having telephone-only contact (two (3%) and 46 (24%)) and children using almost twice as many other health services during care by one CCNT (means 0.27 and 0.51). Conclusions Costs of CCNT care can vary widely when all health service use is taken into account. Differences in the way CCNT are integrated with the urgent care system, and the way in which CCNT care is organised, could contribute to variations in costs.