Posted 18 August 2020 - 06:57
Posted 18 August 2020 - 06:57
Analysis
What will the ‘new normal’ look like for children’s services?
Some of the new strategies adopted to cope with the pandemic are likely to stay
Some of the new strategies adopted to cope with the pandemic are likely to stay
- ‘New normal’ will mean face-to-face appointments resuming, but there is a role for video
- The return of redeployed staff crucial to getting services up and running again
- Nurses share some of the innovations to emerge from the pandemic
As health and social care services aim to return to a ‘new normal’ what does this mean for children’s services heading into the autumn?
While severe cases of COVID-19 in children have been, thankfully, rare – there were reported to have been about 70 intensive care admissions by mid-June – children’s services in general have been hit hard.
Face-to-face appointments in hospital and community services were either conducted online or by phone, or closed down altogether except in for the most urgent cases, while routine surgery was cancelled en masse.
This has resulted in a big backlog of cases. Research by the Royal College of Paediatrics and Child Health estimates 50,000 routine operations on children were postponed in England between March and May. These would have included everything from tooth extractions to spinal surgery.
Nurses are prioritising patients by clinical need
Association of Chief Children’s Nurses chair Sally Shearer says: ‘At the start we didn’t know what to expect, so we made all the same preparations as adults’ services.’
Professor Shearer says chief nurses are now working hard to get services started again, ‘prioritising patients by clinical need’.
In the community this work started in early June, while routine surgery began to get under way a little earlier.
Longer waiting lists despite innovations such as virtual consultations
Professor Shearer says it is taking time. ‘In some trusts theatres are running six or seven days a week to provide more capacity, while others are using the independent sector.
‘But activity can be slower than usual because of the need for personal protective equipment (PPE) and social distancing. It’s going to take a while to tackle the cases that have been delayed.’
She says there will also be longer waiting lists for outpatient appointments, community clinics and child and adolescent mental health services despite the many examples of innovation with virtual consultations that have proved popular with many young people.
Rapid access at stand-alone clinic
Nottingham Children’s Hospital runs community paediatric clinics in 12 different locations, seeing about 1,000 patients a month. But lockdown meant the clinics had to be closed for face-to-face appointments and the service switched to phone consultations.
The team recognised that some patients would still need to be seen for things such as physical examinations, blood tests and other checks.
Bringing them into the main hospital was not desirable, so a rapid-access clinic was set up in a stand-alone building on the hospital site. The building had acted as a base for many community services but was not being used during lockdown.
The building was made COVID-19-secure by the removal of soft toys and furnishings and a one-way system was set up. A phone triage system was created and appointments made for those deemed in urgent need. On arrival families were met outside and screened before being admitted. From April to mid-June nearly 90 children were seen.
Crucial to getting services up and running will be the return of redeployed staff.
Professor Shearer says hospital-based specialist nurses in particular found themselves working in new areas, including intensive care.
‘The concern initially was that intensive care would be stretched or might have to start taking young adults. That was largely avoided.’
Planning and preparation ahead of a possible second wave and winter
It means, she says, that many returned early and staff have been able to take leave, meaning they are ready to restart services and make the most of this planning and preparation period ahead of a possible second wave and winter.
Barts Health NHS Trust director of children’s nursing Kath Evans says she had about 50 children’s nurses redeployed to adult services. In July, the London trust hosted a ‘welcome back’ event for them.
‘We wanted to recognise what they had done as well as discussing what we needed to do to plan for the winter and the next phase of the pandemic.’
Pandemic has provided an opportunity to grasp the agenda
That is going to involve a focus on keeping children out of hospital or, when they are admitted, making sure ‘they don’t spend a minute longer there than necessary,’ she says.
‘That’s going to require good discharge planning and investment in community nursing so more can be done to manage conditions like asthma outside of hospital. In some ways the pandemic has provided a real opportunity to grasp this agenda.
‘We’ve started assessing our frequent attenders to the emergency department to see what can be done to prevent repeat visits. We have changed care plans in some cases and adjusted the support children receive to tackle some of the causes of these attendances.’
Supporting the emotional well-being of children
Ms Evans also believes supporting the emotional well-being of children will be important. ‘There will be children who have lost family during the pandemic, while others will be struggling emotionally because of all that has happened.
‘We need to build the skills of nurses and others on the front line to support children as well as good crisis intervention pathways.’
50,000 children
in England had surgery from all surgical specialities postponed between March and May 2020
The pandemic also seems to be having an impact in other ways. Charity fundraising has been hit as events have been cancelled – and there are signs this could affect children’s services.
The charity that raises cash for Sheffield Children’s Hospital, for example, is seeking to raise £14.25 million to help pay for improvements, including a new cancer ward and emergency department.
Support for children with complex needs has been badly hit
It says the amount it expected to raise this year will likely be down by £2.5 million.
Virtual appointments vital during a difficult time
During the lockdown health visitors could only make face-to-face visits to the most vulnerable families.
But in Hampshire support continued in a variety of ways thanks to digital technology.
Health visitors used the digital video service Visionable to carry out routine appointments in place of home visits, while group sessions supporting parents and the mental well-being of new mothers were carried out via Zoom.
Meanwhile, text messaging support service Chat Health was available for anyone who needed basic advice. Feedback was positive, with parents describing the support as ‘vital’ during such a difficult time.
Southern Health NHS Foundation Trust deputy director of operations children and family services Ginny Taylor says she is pleased with what was achieved, although acknowledges it had its limits.
She says video consultations did not suit everyone – not everyone had smartphones, or data restrictions meant they did not want to take part in video calls – while virtual appointments made it more difficult to pick up on the early signs of problems such as mental health difficulties or domestic abuse.
But she says even though face-to-face appointments are now resuming the service still feels there will be a role for the new technologies. ‘In a large county like ours there are plenty of women who appreciate the choice to do things virtually, particularly parents who have already had a child.’
Meanwhile, outside of hospitals there are fears about the lasting impact that disruption of services will have on the most vulnerable.
At WellChild, a charity for seriously ill children, director of programmes Tara Parker says support for children with complex needs has been hit badly. The charity’s network of more than 40 nurses help support children with life-limiting and life-threatening conditions in and out of hospital.
She says most were redeployed during the pandemic but only half are thought to be back fully.
‘It’s a bit of a mystery why it has been slow getting them back. There maybe a reluctance to return things to normal if a second spike arrives in the autumn.
‘But is it slow or sensible? Children have gone without vital help – respite, physiotherapy and speech and language therapy.
9 out of 10
health visitors saw less than 20% of their contacts face to face at the height of the pandemic
Source: University of Oxford
‘We need to be more intelligent and plan better for any second surge. For example, we know there are 3,500 children in the UK who rely on ventilation. But supplies of equipment have run very low. This was a known quantity and should not have happened.’
Pressures elsewhere in the community
She also says there is still a lack of clarity about how they will be supported to return to school. ‘We must do better for these children.’
There are pressures elsewhere in the community. Health visiting services switched to remote consultations for all but the most vulnerable.
The Institute of Health Visiting warns that this has created a lot of toxic stress during the vital first year for babies and families – something that could have a major impact on the emotional and social development of a generation of infants.
Meanwhile, school nurses report they are beginning to see signs of abuse, neglect, sexual exploitation and worsening mental health problems that went hidden during lockdown.
School and Public Health Nurses Association chief executive officer Sharon White says: ‘Safeguarding referrals went down but it was an artificial calm. We’re now lifting the lid on the pressure cooker.’
She is critical of the way school nurses were deployed in large numbers – sometimes in ‘inappropriate ways’.
Schools were closed, but they were needed more than ever
‘We’ve heard of them being asked to do healthcare assistant roles – these are highly trained public health nurses. In some areas they are still not back.
‘There was an assumption they were not needed because schools were closed. But they were needed more than ever.’
She says where school nurses were kept on they performed some vital tasks, visiting vulnerable children by doing ‘walk and talks’ to keep to social distancing requirements and setting up drive-through clinics for vaccinations.
The School and Public Health Nurses Association was one of more than 150 organisations that sent a letter to prime minister Boris Johnson in June arguing that the pandemic threatens to ‘cast its shadow’ over a generation of children for years to come.
The letter – organised by the Children’s Society, Barnardo’s and the NSPCC – warns against the impact of everything from missing school and rising child poverty to ‘unacceptably long’ waiting lists for mental health treatment.
It calls on the government to make children one of three key pillars in its coronavirus response, alongside health and the economy.
‘What children are facing, especially the vulnerable, is truly terrifying,’ says Ms White.
‘All nurses will be dealing with this one way or other in the coming months.’
Drive-through vaccinations avert backlog
The Isle of Wight school nursing service was part of the way through its vaccination programme when lockdown came. With schools closed and social distancing rules in place nurses could not use their offices for vaccinations.
The team came up with the idea of setting up a drive-through service. Two pods were sourced from the Isle of Wight NHS Trust, each with running water and toilet facilities. They were used to set up the drive-through clinics that were rotated around the island.
A gazebo was also erected with chairs for those who arrived on foot or by public transport. The team started with the year nine students, who were still to get their MenACWY and three-in-one booster vaccinations, to test out the new approach.
They then moved on to year eight students, who needed HPV vaccinations. Strict protocols were put in place. Consent was obtained by phone, while pupils were screened before entering the pod and returned to their family cars to recover.
About 1,200 pupils had been vaccinated by the summer.
School nurse Sarah Toms says: ‘We were delighted with how it went. If we had not been able to do this we would have had a large backlog of cases to catch up next year.’
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